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THE

AMEEICAN JOURNAL

OF THE

MEDICAL SCIENCES.

EDITED BY

ISAAC HAYS, M.D.,

FELLOW OF THE PHILADELPHIA COLLEGE OF PHYSICIANS ; MEMBER OF THE
AMERICAN MEDICAL ASSOCIATION ; OF THE AMERICAN PHILOSOPHICAL SOCIETY ; OF THE
ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA; ASSOCIATE FELLOW
OF THE AMERICAN ACADEMY OF ARTS AND SCIENCES,

&c. &c. &c.

NEW SERIES.
YOL. XLIY.

PHILADELPHIA:
B L A N C H A R D AND LEA.
1862.

69470

Entered according to tlie Act of Congress, in the year 1862, by
BLANCHARD AND LEA,

in the Office of the Clerk of the District Court of the United States in and for the
Eastern District of the State of Pennsylvania.

PHILADELPHIA :
COLLINS, PRINTEE.

AblS
Med.

TO READERS AND CORRESPONDENTS.

We have received a letter from Dr. W. F. Wade, of Birmingham, England,
the author of "a very interesting case of Aortic Aneurism, in which a commu-
nication with the pulmonary artery was recognized during life by means of
Physical Diagnosis," published in the volume of Medico-Chirurgical Transac-
tions for 1861, and reviewed in our No. for April last, p. 473, calling our atten-
tion to a misprint of his name. We regret this mistake, and will ask our sub-
scribers to correct it in their copies.

The following works have been received : —

Transactions of the Obstetrical Society of London. Yol. lY. For the year
1861. With a list of Officers, Fellows, &c. London : Longman & Co., 1862.
(From the Society.)

Public Health in relation to Air and Water. By W. T. Gairdner, M. D.,
F. R. C. P. E., Lecturer on the Practice of Medicine, &c. Edinburgh : Edmon-
ston & Douglass, 1862. (From the Author.)

On Intestinal Obstruction by the Solitary Band. Being a paper read at a
meeting of the Medical Society of London, March 25, 1861, and reprinted from
their Transactions. By John Gay, F. R. C. S., Surgeon to the Great -Northern
Hospital, &c. &c. London, 1861. (From the Author.)

De r Application de la Suture Enchevillee a 1' Operation de I'Entropion Spas-
modique au Moyen d'une Nouvelle Esp^ce de Cheville (cheville jumelle ou a
double branche). Par F. Yauquelin, M6decin Oculists et Auriste a Paris, &c.
Paris : Germer-Bailli^re, 1853. (From the Author.)

Rapport fait a la Society Universelle d' Ophthalmologic par le Secretaire Pro-
visoire. F. Yauquelin, et Descours d'Ouverture par Francesco de Argelagos.
Yersailles, 1861.

A Manual of Medical Diagnosis : being an Analysis of the Signs and Symptoms
of Disease. By A. W. Barclay, M. D., F. R. C. P., Assistant Physician to St.
George's Hospital, &c. &c. Second American from the second and revised
London edition. Philadelphia : Blanchard & Lea, 1862. (From the Publishers.)

Handbook of Surgical Operations. By Stephen Smith, M. D., Surgeon to
Bellevue Hospital, New York. Bailli^re Brothers, 1862. (From the Author.)

A Practical Guide to the Study of the Diseases of the Eye : their Medical
and Surgical Treatment. By Henry W. Williams, M. D., Fellow Massachu-
setts Medical Society, &c. &c. Boston : Ticknor & Fields, 1862.

Experiments and Observations upon the Circulation in the Snapping Turtle,
Chelonura Serpentina, with especial reference to the Pressure of the Blood in
the Arteries and Yeins. By S'. Wier Mitchell, M. D., Lecturer on Physiology.
Philadelphia, 1862. (From the Author.)

A Description of the Newly Invented Elastic Tourniquet, for the Use of
Armies and Employment in Civil Life : its Uses and Applications, with Remarks
on the different Methods of arresting Hemorrhage from Gunshot and other
Wounds. New York, 1862.

TO READERS AND CORRESPONDENTS.

Extension and Counter Extension in the Treatment of Fractures of the Long
Bones, with a description of an Apparatus especially designed for Compound
Fractures. By Joseph H. Vedder, M. D. Flushing, L. I. New York, 1862.

Advice to a Mother on the Management of her Offspring. By Pye Henry
Chavasse, F, R. C. S., &c. &c. Reprinted from the sixth London edition. New
York : Ballifere Brothers, 1862.

Quarterly Summary of the Transactions of the College of Physicians of
Philadelphia.. From September 4, 1861, to February 5, 1862, inclusive. Phila-
delphia, 1862.

Proceedings of the Academy of Natural Sciences of Philadelphia. January,
February, March, April, 1862.

Mortuary Tables of San Francisco. Arranged by A. F. Sawyer, M. D.,
January, 1862. San Francisco, 1862. (From the Author.)

The Action of the Voluntary Muscles. By Louis Mackall, M. D. Alexan-
dria, 1862. (From the Author.)

The Annual Address before the Medical Society of the State of New York,
and the Members of the Legislature, delivered in the Capitol, February 6, 1862.
By Edward H. Parker, M. D., President of Society. Poughkeepsie, 1862.
(From the Author.)

Address before the Philadelphia County Medical Society. Delivered Jan-
uary 30, 1862. By Joseph Carson, M. D., at the close of his official term as
President. Printed by order of the Society. Philadelphia, 1862. (From the
Author.)

An Address delivered before the BuflFalo Medical Association, April 1, 1862.
By Dr. C. C. F. Gay, President of the Association, on retiring from the chair.
Published by vote of the Association. Buffalo, 1862.

Valedictory Address to the Graduating Class of the Cincinnati College of
Medicine and Surgery. Delivered February 12, 1862. By A. H. Baker, M. D.,
Professor of Surgery. Cincinnati, 1862.

Forty-fifth Annual Report on the State of the Asylum for the Relief of Per-
sons deprived of their Reason. Published by direction of the Contributors.
Philadelphia, 1862. (From Dr. J. H. Worthington, Physician and Superin-
tendent.)

Second Annual Report of the Superintendent of Clifton Hall, a Private
Hospital for Mental Diseases, to the Board of Supervision, for the year 1861.
Philadelphia, 1862. (From R. A. Given, M. D.)

Fourth Annual Report of the Medical Board of the Charity Hospital of
Philadelphia to the Board of Trustees, January 1, 1862. Philadelphia, 1862.
(From Dr. A. M. Slocum.)

The following Journals have been received in exchange : —
Gazette M6dicale de Paris. February, March, 1862.

Annales Medico-Psychologiques. Redege par MM. les Docteurs Baillarger,
Cerise, et Moreau (de Tours). January, 1862.

TO READERS AND CORRESPONDENTS.

Gazette Hebdomadaire de Medecine et de Chirurgie. Redacteur en chef, A. "
Dechambre. Tom. IX., Nos. 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17,
18, 20, 21, 22. 1862.

Journal de Medecine de Bordeaux. Redacteur en chef, M. Costes. January,
February, March, 1862.

Edinburgh Medical Journal. March, April, 1862.

British and Foreign Medico-Chirurgical Review. April, 1862.

The Glasgow Medical Journal. April, 1862.

The Dublin Quarterly Journal of Medical Science. May, 1862.

Medical Times and Gazette. April, May, June, 1862.

Dublin Medical Press. March, April, May, 1862.

The Medical Critic and Psychological Journal. Edited by Forbes Wjnslow,
M. D., D. C, L. Oxon. April, 1862.

London Medical Review. March, April, 1862.

The Madras Quarterly Journal of Medical Science. January, 1862.

The Medical Record of Australia. Edited by Dr. Reeves, January, 1862.

The British American Journal. Edited by Archibald Hall, M. D. March,
May, 1862.

Boston Medical and Surgical Journal. Edited by F. E. Oliver, M. D., and
S. L. Abbot, M. D. April, May, June, 1862.
American Medical Times. April, May, June, 1862.

The Cincinnati Lancet and Observer. Edited by Ed. B. Stevens, M. D., and
J. A. Murphy, M. D. April, June, 1862.

Ohio Medical and Surgical Journal. Edited by the Professors of Starling
Medical College. March, May, 1862.

The American Journal of Insanity. Edited by the Medical Officers of the
New York State Lunatic Asylum. April, 1862.

The American Journal of Science and Arts. Edited by Professors B. Silli-
MAN, B. SiLLiMAN, Jr., and Jas. D. Dana. May, 1862.

The Chicago Medical Journal. Edited by D. Brainard, M. D., and J. A.
Allen, M. D. April, May, June, 1862.

The Chicago Medical Examiner. Edited by N. S. Davis, M. D., and F. W.
Reilly, M. D. March, April, May, 1862.

Buffalo Medical and Surgical Journal and Reporter. Edited by Julius F.
Miner, M. D. April, May, June, 1862.

American Medical Monthly. Edited by J. H. Douglas, M. D. April, May,
June, 1862.

The Pacific Medical and Surgical Journal. Edited by James Blake, M. D.
February, March, April, May, 1862.

The Cincinnati Medical and Surgical News. Edited by A. H. Baker, M. D.,
and J. A. Thacker, M. D. March, April, May, 1862.

San Francisco Medical Press. Edited by E. S. Cooper, A. M., M. D. April,
1862.

TO READERS AND CORRESPONDENTS.

The American Journal of Ophthalmology. Yol. I., No. 1. Julius Hom-
BERGER, M.D., editor and proprietor. New York. July, 1862.

American J ournal of Pharmacy. Published by authority of the Philadelphia
College of Pharmacy. Edited by Wm. Proctor, Jr., Professor of Pharmacy in
Philadelphia College of Pharmacy. May, 1862.

The American Druggists' Circular and Chemical Gazette. April, May, June,
1862.

The Dental Cosmos. Edited by J. D. White, M.D., J. H. McQuillan, D.
D. S., and Geo. J. Ziegler, M.D. April, May, 1862.

Communications intended for publication, and Books for Review, should be sent,
free of expense, directed, to Isaac Hays, M. D., Editor of the American Journal of the
Medical Sciences, care of Messrs. Blanchard & Lea, Philadelphia. Parcels directed
as above, and (carriage paid) under cover, to Messrs. Triibner & Co., Booksellers,
No. 60 Paternoster Row, London, E. C. ; or M. Hector Bossange, Lib. quai Voltaire,
No. 11, Paris, will reach us safely and without delay. We particularly request
the attention of our foreign correspondents to the above, as we are often subjected
to unnecessary expense for postage and carriage.

Private communications to the Editor may be addressed to his residence, 1525
Locust Street.

All remittances of money, and letters on the business of the Journal, should be
addressed exclusively to the publishers, Messrs. Blanchard & Lea.

The advertisement-sheet belongs to the business department of the Journal,
and all communications for it should be made to the publishers.

To secure insertion, all advertisements should be received by the 20th of the
previous month.

CONTENTS

OF THE

AMERICAN JOURNAL

OF THE

MEDICAL SCIENCES.

NO. LXXXYII. NEW SERIES.
JULY, 1862.

ORIGINAL COMMUNICATIONS.

MEMOIRS AND CASES.

ART. PAGE

L Remarks on Fungi, with an account of Experiments showing the Influ-
ence of the Fungi of Wheat Straw on the Human System ; and some
Observations which point to them as the Probable Source of " Camp
Measles," and perhaps of Measles generally. By J. H. Salisbury, M. D.,
of Newark, Ohio. (With a plate containing twenty figures.) . . 17

II. On Cardiac Murmurs. By Austin Flint, M. D., Professor of the Prin-
ciples and Practice of Medicine iia the Belle vue Hospital Medical College,
New York, and in the Long Island College Hospital 29

III. On Smallpox, and the Means of Protection against it. By S. Henry
Dickson, M. D., Professor of the Practice of Medicine in Jefferson Medi-
cal College, Philadelphia. 54

lY. Amaurosis and other Disorders of the Eye, resulting from Injury of
the Terminal Branches of the Fifth Pair of Nerves. By Frederic D.
Lente, M. D., of Cold Spring, New York. 70

Y. On Burns. By John Ashhurst, Jr., M.D., late Senior Resident Sur-
geon to the Pennsylvania Hospital. 82

YI. On the Employment of India-rubber in obtaining Continuous Exten-
sion in the Treatment of Fractures of the Femur. By John H. Packard,
M. D., of Philadelphia. (With a wood-cut.) 88

YII. On the Epidemic Relationship of Zymotic Diseases. By E. P. Chris-
tian, A. M., M. D., Wyandotte, Michigan 91

YIIL Description of a Pseudencephalic Monster. (Genus 11, Thlipsence-
phalus, Isidore Geoff. St. Hilaire.) By Christopher Johnston, M. D.,
Baltimore. (With three wood-cuts.) 96

IX. Cases treated at the Medical Missionary Society's Hospital at Canton,
China. By John G. Kerr, M. D. (Communicated by Professor S. D.
Gross, M.D.) . . 99

X. Case of Puerperal Uraemia. By Y. J. Fourgeaud, M. D. of San Fran-
cisco, California 103

TRANSACTIONS OF SOCIETIES.

XL Summary of the Proceedings of the Pathological Society of Phila-
delphia 105

Singular Lesion of the Urinary Bladder. By Dr. Packard. . . 105
Compound Comminuted Fracture of the Skull, and Fracture of Ribs.

By Dr. Ashhurst 106

Gangrene of the Lung. By Dr. Leet 107

CONTENTS.

ART. PAGE

Mammary Carcinoma. By Dr. Ashhurst 107

Eupture of the Urethra. By Dr. Lee 108

Gunshot Wound of Femur and Pubis. By Dr. Packard. . . 109

Deformity of Legs. By Dr. Lee 110

Incarcerated Hernia. By Dr. Lee Ill

Compound Comminuted Fracture of Thigh; Fracture of Scapula

and of Ribs, with Scalp Wounds and Effusion on Brain. By Dr.

Ashhurst ' . 112

Compound Fracture of Sacrum. By Dr. Lee. .... 113
Compound Comminuted Fracture of Skull ; Fracture of Pelvis and

Rupture of Bladder. By Dr. Lee 114

Ruptured Peritoneum. By Dr. Ashhurst 114

Comminuted Fracture of Pelvis, Fracture of Thigh, &c. By Dr.

Lee 115

Tubercle of Kidney. By Dr. Ashhurst 116

Metastatic Abscesses. By Dr. Packard. 117

Deficiency in the number of Ribs. By Dr. Packard. . . . 118

REVIEWS.

XII. Theories of Life and Organization.

1. Recherches Physiologiques sur la Yie et la Mort. Par F. X. Bichat.
Nouvelle Edition, precedee d'une Notice sur la vie et les Travaux de
Bichat et suivie de Notes par le Docteur Cerise. Paris : Yictor Masson
et Fils, 1862. 8vo. pp. 382.

2. De la Yie et de I'lntelligence. Par P. Flourens, Membre de I'Academie
Francaise et Secretaire perpetual de I'Academie des Sciences (Institut
de France), etc. Paris : Garnier Freres, 1858. 8vo. pp. 161.

3. La Medecine Nouvelle bas6e sur des Principes de Physique et de Chimie
transcendantes et sur des Experiences capitales qui font voir mecanique-
ment I'origine du Principe de la Yie. Par L. Lucas. Paris : F. Savy,
1861. Tome ler. 8vo. pp. 504.

4. La Yie dans I'Homme; Existence, Fonction, Nature, Condition pr6-
sente, Forme, Origine et Destinee future du Principe de la Yie ; Esquisse
Historique de TAnimisme. Par J. Tissot. Paris : Yictor Masson et
Fils, 1861. 8vo.

5. La Yie dans I'Homme ; ses Manifestations diverses, leurs Rapports, leurs
Conditions Organiques. Par J. Tissot. Paris : Y. Masson et Fils, 1861.
8vo. pp. 614.

6. Discours sur le Yitalisme et I'Organicisme et sur les Rapports des Sci-
ences Physiques en General avec la Medecine : Discours prononce a
I'Academie Imperiale de Medecine, 17 Juillet, 1860. Par M. le Profes-
seur Bouillaud. Paris, 1860. 8vo. pp. 75 119

XIII. Epilepsy : its Symptoms, Treatment, and Relation to other Chronic
Convulsive Diseases. By J. Russell Reynolds, M. D., Lond. London,
1861. 8vo. pp. 360.

Epileptic and other Convulsive Affections of the Nervous System, their
Pathology and Treatment. By Charles Bland Radcliffe, M. D. Third
edition. London, 1861. 12mo. pp. 312 134

XIY. Traite de Chirurgie Navale. Par Louis Saurel, Chirurgien de la
Marine, Professor agreg6 a la Faculty de Medecine de Montpelier, Cor-
respondant de la Societe de Chirurgie de Paris ; Suivi d'un resume de
lecons sur la service chirurgical de la flotte. Par le Docteur J. Rochard,
Chirurgien en chef de la Marine, Professor k I'Ecole de Medecine Navale
du port de Brest, Officier de la Legion d'honneur. Illustr6 de 186
planches intercalees dans le texte. 8vo. pp. 592 + 104. J. B. Ballifere
et Fils. Paris, 1861.

Treatise on Naval Surgery. By Louis Saurel, Surgeon of the Navy, &c.,
followed by a summary of lectures on the surgical service of the fleet.
By Doctor J. Rochard, Surgeon in Chief of the Navy, &c. Paris, 1861. 149

CONTENTS.

ART. PAGE

XV. Lectures on the Germs and Yestiges of Disease, and on the Preven-
tion of the Invasion and Fatality of Disease by Periodical Examinations.
Delivered at the Royal Infirmary for Diseases of the Chest. By Horace
Dobell, M. D., &c. &c., Physician to the Infirmary. London, 1861. 8vo.
pp. 198 157

BIBLIOGRAPHICAL NOTICES.

XYI. Reports of American Institutions for the Insane.

1. Of the Butler Hospital, for the year 1860.

2. Of the New Jersey State Hospital, for the year 1860.

3. Of the Western Asylum of Virginia, for the fiscal year 1859-60.

4. Of the State Asylum of South Carolina, for the year 1860.

5. Of the Northern Ohio Asylum, for the fiscal year 1859-60.

6. Of the Hamilton County (Ohio) Asylum, for the fiscal year 1858-59.

7. Of the Asylum of California, for the year 1858.

8. Of the Wisconsin State Hospital, for the year 1860 165

XVII. Lectures on the Diagnosis and Treatment of the Principal Forms
of Paralysis of the Lower Extremities. By E. Brown-S6quard, M. D.,
F. R. S., Fellow of the Royal College of Physicians of London, Hon.
Fellow of the Faculty of Physicians and Surgeons of Glasgow, Laureate
of the Institute of France (Academy of Sciences), etc. etc. 8vo. pp. 118.

J. B. Lippincott & Co. : Philadelphia, 1861. . . . . . .175

XVIII. Surgical Tracts.

1. Amputation of the Cervix Uteri. By J. Marion Sims, M. D. Extracted
from the Transactions of the State of New York, 1861. New York, 1861.
8vo. pp. 16.

2. Extension and Counter-extension in the Treatment of Fractures of the
Long Bones; with a Description of an Apparatus especially designed for
Compound Fractures. By Joseph H. Vedder, A. M., M. D. New York,
1862. 8vo. pp. 23.

3. A Description of the newly-invented Elastic Tourniquet, for the Use of
Armies and Employment in Civil Life, its Uses and Applications, with
Remarks on the Different Methods of Arresting Hemorrhage from Gun-
shot and other Wounds. New York, 1862; 8vo. pp. 31.

4. On Intestinal Obstruction by the Solitary Band. Being a paper read at
a meeting of the Medical Society of London, March 25th, 1861, and re-
printed from their Transactions. By John Gay, F. R. C. S., &c. London,
1861. Printed for private circulation. 8vo. pp. 16 179

XIX. Handbook of S.urgical Operations. By Stephen Smith, M.D., Surgeon

to Bellevue Hospital. New York : Bailliere Brothers, 1862. 12mo.pp.279. 181
■ XX. Transactions of the Obstetrical Society of London. Vol. III. 8vo.
pp.480.. London, 1862 182

XXI. Public Health in Relation to Air and Water. By W. T. Gairdner,
M. D., Fellow of the Royal College of Physicians, Edinburgh ; Physi-cian
to the Royal Infirmary, and Lecturer on the Practice of Medicine. 12mo.

' pp. 369. Edinburgh, 1862 192

XXII. The Ambulance Surgeon, or Practical Observations on Gunshot
Wounds. By P. L. Appia, M. D., Fellow of the Royal Society of Naples,
&c. Edited by T. W. Nunn, Assistant Surgeon to the Middlesex Hos-
pital, and A. M. Edwards, F. R. S. E., Lecturer on Surgery in the Edin-
burgh Medical School. Edinburgh, 1862. 12mo. pp. 266. . . .200

XXIII. Experiments and Observations upon the Circulation in the Snap-
ping Turtle, Chelonura Serpentina, with especial Reference to the Pressure
of the Blood in the Arteries and Veins. By S. Wier Mitchell, M. D.,
Lecturer on Physiology. Philadelphia, 1862. 4to. pp. 14. . . . 201

XXIV. A Manual of Medical Diagnosis : being an Analysis of the Signs
and Symptoms of Disease. By A. W. Barclay, M. D., F. R. C. P., As-
sistant Physician to St. George's Hospital, &c. &c. Second American,
from the second and revised London edition. Philadelphia : Blanchard

& Lea, 1862. 8vo. pp. 451 202

CONTENTS.

QUAKTERLY SUMMARY

OF THE

IMPROVEMENTS AND DISCOYERIES IN THE
MEDICAL SCIENCES.

FOREIGN INTELLIOENCE.

Anatomy and Physiology.

PAGE

1. On the Tactile Sensibility of tlie
Hand. By Dr. Ballard. . . 203

2. Yalves of tlie Yeins of tlie Ex-
tremities. By M. Verneuil. . 204

PAGE

3. Marriages of Consanguinity and
Deaf-Dumbness. By M. Boudin. 205

4. Marriages of Consanguinity and
their Influence on Offspring. By
Dr. Mitchell 205

Materia Medica and Pharmacy.

5. Action of Alcohol as an Ali-
ment in Disease. By Dr. F. E.
Anstie 208

6. Therapeutic Properties of the
Peroxide of Hydrogen. By Dr.
Eichardson 209

7. Podophylliu. By Dr. Gardner. 210

8. Therapeutical Properties of
Malt. By M. Fremy. . .212

9. Substitution of Daturia for
Atropia. By M. Jobert. . . 212

10. Antiseptic Properties of Am-
monia. By Dr. Eichardson. . 212

11. Inhalation of Pulverized Fluids.

By M. Poggiale. . . .214

12. Administration of Cod-Liver
and other Oils, By Dr. Alex-
ander Wallace. . . . 214

13. New Preparation from Chloro-
form. By Dr. Thomas Skinner. 215

14. Vesicating Collodion. By Mr.

C. E. C. Tichborne. . . .216

15. Solid Creasote. By M. Stanis-
laus Martin 217

16. Inefficiency of Hyoscyamus as
usually prescribed. By M. Do-
novan. . . . . . 218

Medical Pathology and Therapeutics, and Practical Medicine.

17. On the Exhibition of Food in
Typhoid Fever. By M. Herard. 218

18. Quinine as a Prophylactic of
Fever. By Dr. Smart. . . 221

19. Clinical Inquiry into the Use
of Iron in Pulmonary Consump-
tion. By Dr. James Jones. . 221

20. Chlorate of Potassa in Phthi-
sis. By Dr. E. P. Cotton. . 223

21. Delirium Tremens treated by
Large Doses of Digitalis. By
Mr. Hester 224

22. Treatment of Pleurisy. ByM.
Trousseau. . . . - . 226

23. Pneumonia in Infants. By M.
Barthez. . . . . . 226

24. Treatment of Cancrum Oris.
By Dr. Alexander Keiller. . 227 !

25. Pathology and Treatment of
Jaundice. By Dr. Geo. Harley. 230

26. Treatment of Dysentery. By
Dr. Smart 231

27. Subnitrate of Bismuth in Di-
arrhoea and Chronic Dysenterv.
By Dr. Gaubert. . . 231

28. Saccharine Treatment of Dia-
betes Mellitus. By John Hughes,
M.D 232

29. Chorea treated by Sulphate of
Aniline. By Dr. Morell Mack-
enzie. 235

30. Individual Eemedies in Epi-
lepsy. By Dr. Anstie. . .235

31. Statistical Inquiry into the
Prevalence of Numerous Condi-

! tions affecting the Constitution

CONTENTS.

in one thousand Phthisical Pa-
tients when in Health. Bv Dr.
Edward Smith. . . . 236

32. Brass Founders' Ague; Dis-
ease produced br Fumes of Zinc.

By Dr. Greenhow. . . .238

33. Sudden Death from Emboli.

By M. Briquet. . . .239

34. Case of Syphilitic Disease ap-
pearing in two Healthy Children

PAGE

after Vaccination from a Syphi-
litic Child. ByDr.N. J.Haydon. 239

35. Yalue of ^gophony as a Sign

of Pleurisy. By Prof. Landouzy. 240

36. Tsenia Solium. ByM.Mauche. 240

37. On the Probabilities of the
Duration of Life in the Apo-
plectic and the Phthisical. Dr.
Bruckner 241

SuKGiCAL Pathology axd Theeapeutics, axd OPERATiyE Surgery.

38. Treatment of Burns. By Prof.
Eoser. . . . \ .242

39. Traumatic Tetanus cured by
Chloride of Barium. By Dr.
Gnecchi 243

40. The Influence upon the Growth
of the Bones of Paralysis, Dis-
ease of the Joints, Disease of the
Epiphysial Lines, Excision of
the Knee, Pickets, and some
other Morbid Conditions. By
Dr. G. M. Humphry. . . 244

41. Ligature of the Common Ca-
rotid. By Dr. Redfern Dayis. . 245

42. Operations for the Cure of
Varicocele and Varicose Veins. .
By Dr. M. H. Collis. . . 246

43. Stability of the Cure of Va-
rices. By M. Blot. . . .247

44. True Anchylosis of the Left
Hip -Joint, from Rheumatism;
the limb at a right angle to the
body, and abducted; excision of
a wedge-shaped piece of the
femur; cure. By Dr. H. V.
Berend 247

45. Dislocation of the Ulna for-
wards without Fracture of the
Olecranon. By M. Caussin. . 248

46. Dislocation of the Foot For-
wards. By Dr. Demarquay. . 248

47. Fracture of a Rib produced by
a Sneeze. By Dr. D. F. Cas-
tella 249

48. Transverse Fracture of the
Patella. _ By Mr. Holthouse. . 249

49. Statistics of Amputations at
the Hospitals of Paris. By Dr.
Ulysses Trelat. . ." .250

50. Perforating Gunshot "Wound
through the Thickness of the
Lung; Recoyery. ByDr.Voods. 250

51. Difficulties in the Treatment
of Umbilical Hernia. By M.
Huguier " . 252

52. Ether and Belladonna in Stran-
gulated Hernia. By Dr. Burk-
hardt. . . ^ . .253

53. Camphorated Chloroform as a
Local Anaesthetic in Extirpation
of the Toe Nail. By M. Mar-
tenot de Cordoux. . . . 253

54. Congenital Inyersion of the
Bladder; Cure. By J. Lowe,

M. D 253

55. The Cochin China Ulcer. By

M. Pochard. . . . \ 254

Ophthalmology.

56. Frequent Eyacuation of the
Aqueous Humour as a Means
of Causing the Absorption of
Cataract. By Prof. Sperino. .

57. Hereditary Amaurosis. By
Mr. Sedgwick

58. Amaurosis cured by Eyacua-
tion of the Aqueous Humour. .

59. Retinitis Leuksemica. By Dr.
Liebreich. ....

60. Embolism of the Arteria Cen-
tralis Retinte. By Dr. Liebreich.

61. Loss of an Eye from the Bite

of a Leech. By Professor Von

Graefe 259

62. Piece of Stone Imbedded for

255 Seyen Months in the Cornea.

By Dr. Wm. Hutchinson. . 259

256 63. Rectification of Diyergent

Strabismus by the Methodical

257 Use of Prismatic Glasses. By
Dr. Giraud-Teulon. . . \ 259

258 64. Hemorrhage into the Anterior
I Chamber of the Eye. supplemen-

258 i tary to the Menstrual Flux. By
i M. Guepin. . . . 261

CONTENTS.

Midwifery.

. 261

263

PAGE

65. Meclianism of Labour. By Dr.
Halahan. .

66. Induction of Premature La-
bour in Cases of Constitutional
Affections. By Dr. Keiller.

67. Internal Surface of the Uterus
after Delivery. By Dr. J. Mat-
thews Duncan

68. Unsuspected Pregnancy and
Labour. By Dr. H. Tanner.

69. Twins; One Dead at Six
Months ; Both Eetained until
full Term. By Dr. Flecken. . 266

70. Diagnosis of the Sex of the
Foetus. By Dr. Steinbach. . 266

71. Epidemic of Puerperal Phleg-

265

PAGE

monous Erysipelas at Stockholm.
By Prof. Retzius. . . .269

72. Treatment of Peritonitis by the
Continued Application of Cold

to the Abdomen. By M. B6hier. 270

73. Broncho-Pneumonia of Lying-
in Women. By Dr. Barnes. . 271

74. Ovarian Tumour cured by Tap-

pmr

and followed by Two

Pregnancies. By M. L. R.
Cooke

75. Intra-Uterine Convulsions. By
Dr. James A. Sidey.

76. Pathogeny of Retro-Uterine
Hsematocele. By Prof. Braun.

271

272

273

Medical Jurisprudence and Toxicology.

77. Additional Experiments on the
Poisonous Effects of Coal Gas
upon the Animal System. By

Dr. C. J. B. Aldis. . . .274

78. Connection between Poisoning
by Phosphorus and Fatty De-

generation of the Liver. By
Dr. Lewin. . . . .275

79. Poisoning by Aniline and by
Nitro-Benzol 275

80. New Mode of Detecting Minute
Traces of Morphia. By M. Le-
fort 276

AMERICAN INTELLIGENCE.

Original Communications.

Case of Opium Poisoning in which
Belladonna was successfully used
as an Antidote. By W. S. Dun-
can, M. D 277

Clover-Hay Tea in Hooping-Cough.
By Dr. Condie 278

Prolonged Abstinence. By Geo.
Ord, Esq 278

Case of Monstrosity. By L. W.
Baker, M.D 278

Syrup of Triticum Repens in Irri-
table Conditions of the Urinary
Bladder. By the Editor. . 279

Domestic Summary.

Case of Poisoning by Laudanum —
Belladonna used as an Antidote.
By Dr. James Blake. . . 280

On the Non-Shortening of the Su-
pra and Infra-Yaginal Portion
of the Cervix Uteri. By Dr.
Isaac E. Taylor. . . .281

Body Transfixed by a Bayonet ;
Recovery. By Dr. B. J. D. Irwin. 283

Inversion of the Uterus of Thirteen
Years' Standing reduced by a
Novel Method. By Dr. E, Noeg-
gerath. 283

Nitric Acid in Hooping Cough.
By Dr. S. W. Noble. . . 284

Seeds of the Cucurbita Pepo, or
Pumpkin, in Taenia. By Dr. G.
R. Patton 284

Staphyloma of Cornea ; Iridecto-
my ; Suppuration of Globe. By
Dr. Henry D. Noyes. . . 284

Polypus of the Ear successfully
destroyed by the Persulphate of
Iron. By Dr. E. L. Holmes. . 285-

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES

FOR JULY 186 2.

Art. I. — Remarks on Fungi, ivifJi an account of Experiments sJioicing
the Influence of the Fungi of Wheat Straw on the Human System; and
some Observations ichich point to them as the P7vbable Source of Camp
Measles,''^ and perhaps of Measles generally. By J. H. Salisbury, M.D.,
of Newark, Ohio. (With a plate containing twenty figures.)

The fungi belong to the lowest types of vegetable existence. Unlike the
higher orders of plants, they are developed almost entirely in darkness (not
being able to decompose carbonic acid under the influence of light), and they
depend upon decaying or decomposing organic matter for the materials of
their growth. They differ from flowering plants in their chemical influence
upon the air. Like animals, they absorb oxygen and give out carbonic
acid. Decay is an essential condition to their development. Besides
organic decomposition, a certain degree of heat and moisture must exist.
These three conditions are requisite, to excite their vegetative activity —
but in very different degrees in the different families. There is another
peculiarity ; their cells contain a large percentage of nitrogenized matter,
making their composition more analogous to animal matter, than to the
higher orders of plants. Their growth and maturity are usually rapid —
requiring often but a few hours — and with almost equal rapidity they
decay. The odours they emit in decay are more like those of putrescent
animal than of vegetable matter. There are exceptions to this, however,
in those families where their textures are of an almost woody firmness and
of a slow growth, as in many of the Polypori and Boliti.

The fungi are variously distributed among organized nature; each species
growing only upon such bodies (even though the temperature and moisture
be rightly adapted) as will furnish to it the materials from which it can
make the proximate products that are peculiar to it. For instance, the
No. LXXXYII.— July 1862. 2

18 Salisbury, Effects of Fungi on Human System. [July

gory dew and red snow (Protococcus nivalis) form invariably a peculiar
red secretion, to which they owe their colour; and they will grow only
where they can obtain the elements to form this red matter. The yeast
plant {Peyiicillium) invariably forms an albuminous secretion, and it will
vegetate only in bodies which can supply the materials for this substance.
From this it would appear that peculiar states and combinations of organ-
ized matter control mainly the developmental distribution of parasitic fungi.
The spores planted in their proper soil, only demand in addition a certain
amount of moisture and degree of temperature — these present, they rapidly
develop.

Those Fungi known by the common name of mould, mildew, smut, &c.,
attach themselves to and are developed from living tissues as well as from
dead organic matter ; yet in both cases they depend alike upon decay for
their development.

In plants we have common examples of this in the Uredo, which attacks
tlie-maire plant; the Secali, which attacks the rye plant ; the Fuccinea,
which attacks the rose bush ; the Botrytis infestans, which causes the
potatoe.rot; the Merulius lacrymans and Folyporus destructor, which
cause dry rot in timber ; the Sphderia morhosa, which attacks plum trees ;
the Oidium, which produces decay in fruit ; the Fenicillium and Asper-
gillus, which attack bread and cheese ; and the yeast and vinegar plants,
which are submerged stems or mycelia of the Fenicillium. The savin or
juniper tree is attacked by a peculiar genus — Fodisoma — which bursts from
the bark and swells under the influence of moisture to a gelatinous mass ;
and the black irregular scars on apples are produced by the Spilocena
fructigena.

Others attack the housekeepers' preserved fruits, paste, mustard, and even
clothing. Others the farmers' grain and grass ; the vintigers' grapes ; and
the gardeners' vines, vegetables, and flowers. Scarcely any vegetable pro-
duction, either living or dead, escapes the ravages of these parasites.

Animals also have their parasitic fungi. The disease (in Italy and the
South of France) termed Muscadine, which sometimes attacks the cater-
pillars of the silkworm in large numbers, just when they are about to enter
the chrysalis state, has been ascertained to be due to the growth — within
their bodies — of a minute fungus {Botrytis hassiana) nearly resembling
the common mould.

It is capable of being communicated from one individual to another. It
spreads in the fatty tissue beneath the skin, occasioning its destruction.
The fungus spreads by the extension of its own stems and branches, and by
the production of numerous sporules, which in their turn vegetate, and
finally produce the death of the worm.

The flies found adhering to our windows are destroyed by a mould
(Sporendonema muscae) which produces the little white rings between the
abdominal segments and discharges its spores upon the glass around like a

1862.] Salisbury, Effects of Fungi on Human System. 19

little cloud. In the West Indies, it is not at all uncommon to see indivi-
duals of the species Polistes (a wasp-like insect) flying about with plants,
their own length, projecting from some part of the body. In time this
growth spreads through the whole body, causing death ; after which the
plants grow with much more luxuriance from the dead body than they
formerly had from the living.

A similar growth {Cordyceps Robertsii) takes place in the bodies of
certain caterpillars in New Zealand, Australia, and China. Some of our
American caterpillars are destroyed by the Cordyceps militaris. The
Onygena exigua attacks the hoofs of the horse, and the hoofs and horns
of cattle. (The Isariafelina is found in the feces of cats deposited in dark
and obscure places.)

In certain diseased conditions of the cutaneous surface — in man — named
Porrigo favosa and Sycosis menti, a considerable development of fungous
vegetation takes place ; and the same has been discovered to be true of the
white patches {Aplithse) on the lining membrane of the mouth in children,
which are known as thrush. In all these cases, however, a certain morbid
condition of the animal fluids must exist in order that the germs of the
fungus may develop themselves ; so that the condition, rather than the
presence of the fungus must be looked upon as the essence of the disease.^
The individual cells and spores of the Fungi are microscopic, and so light
that they are suspended in and borne about by the air. They are so minute
that they permeate alike the tissues of animals and plants. Whenever it
happens that the spores enter matter that is suited to their sustenance, and
the proper amount of heat and moisture are present, they rapidly develop.
It would be very strange if very many abnormal conditions of living tissues
were not produced by this insidious vegetation. The plants being mostly
microscopic, and requiring often but a few hours for their development and
decay, renders their discovery one fraught with far greater difficulty than
would at first be supposed. When no development of the spores takes
. place in the tissues, no doubt in many instances they exercise a deleterious
influence by their presence alone, as many of the larger and better known
fungi have been ascertained to possess peculiar poisonous properties, which,
in their action on the human system, resemble much in their depressing
effects the animal poisons.

With these preliminary remarks we enter upon —
Some observations connected with measles and the fungi ofioheat straiu.

Hon. J. Dille, of Newark, Ohio, came to my office on the evening of the
9th of December last, and stated that he was just recovering from what he
believed to be an attack of measles. It was his opinion he had caught them
from pitching straw from an old stack. He stated that on December 4th
he pitched from an old stack a load of straw, and unloaded it in his stable.

' Carpenter's General and Comparative Physiology.

20 Salisbury, Effects of Fungi on Human System. [July

Portions of the stack had become partially decayed, and was already steam-
ing with the heat of incipient decomposition. In pitching over and picking
out the best straw the air became filled with a fine dust, which he freely
inhaled. The dust tasted and had the odour of old straw. This took
place during the forenoon. His throat soon began to feel dry and irritated.
When he returned to dinner, he could still taste and smell the old straw.
This taste and smell he could not get rid of. During the following night
he awoke with a very sore throat, which became much worse by morning.
After getting up and dressing he was taken with a severe chill, with pains
in the head and back, and felt so sick and prostrated that he was compelled
to return to bed again, where he remained through the day. The chill was
followed by a high fever and severe pains in the head, so much so that a
portion of the time he was delirious. He felt a heavy congested feeJing
about the chest, his throat and fauces were swollen and inflamed, with severe
catarrhal symptoms. An eruption like that of measles appeared on his face
and neck, and the old straiv taste still continued. His fever continued high
through the following (Thursday) night, with severe pains in the head.

Friday, December 6th, he felt much better, and was able to be up around
the house. The fever and catarrhal symptoms had partially subsided. His
eyes were sensitive, watery, and inflamed.

Saturday, December tth, felt much better. The eruption had passed
downward over the whole body, and had begun to disappear from the face.
He rapidly recovered, so that on Monday, December 9th, he was moving
about the streets. In the evening of the 9th he called at my office. His
eyes were still reel, inflamed, and sensitive ; throat sore, dry, and voice
hoarse, and had a heavy congested feeling still about the chest. The
blotches on his face could be faintly distinguished. He stated that he could
still taste the old straw in his throat.

Measles at Gamp Sherman. — At the military camp — Camp Sherman —
Newark, Ohio, the measles first appeared on Dec. 4th, the same day that
Mr. Dille exposed himself to the straw dust. From Nov. 23d to 30th,
the weather was cool, damp, with considerable sleety rain and snow.
During this time (there being between six and seven hundred men in camp),
many of the tents were furnished with ticks, which were filled with straw
for the men to sleep on. In the centre of each tent was a fire, built in a
hole in the ground, from which the smoke was led off by an underground
flue, extending to the outside of the tent. The straw ticks were arranged
around the fire, several in a tent, and each tick accommodated two men.
On Dec. 1st, the weather became colder and snow fell to the depth of about
an inch. On the 2d — which was quite warm — this melted and wet the
soil and dampened the straw ticks. Dec. 4th, the measles made their first
appearance in Camp Sherman. The men came from different parts of the
county, and no one knew that he had been exposed to the disease. Some
had been in camp two weeks, and no one supposed to have that disease
had visited the camp. Subsequent inquiries have failed to discover any
one who brought them there, or to account for their appearance from the
contagion of the disease. On the first day (Dec. 4th) there were eight
cases, and within a week after there were forty. The disease then disap-

1862.] Salisbury, Effects of Fungi on Human System. 21

peared for 10 or 12 days from its first appearance. Between the 14tli and
16tli the disease again made its appearance, and within a few days there
were between forty and fifty cases more, when the disease ceased altogether.
These last cases, occurring so near the usual time at which the disease ordi-
narily makes its appearance after exposure, renders it probable that they
were communicated from the first cases.^

On the 3d of Dec. it became warm and pleasant as growing weather in
spring — and continued warm and delightful till Dec. 10th. On the 11th
and 12th it was cold and freezing. The 13th and 14th were cool. From
the 15th to the 21st the weather was warm and pleasant.

The following is the statement of Mr. S. — "In JSTovember, 1842, I
returned home from school on a Friday. My father had the threshers, with
a machine, threshing wheat. The wheat had been stowed away in the
mow and in a couple of stacks outside the barn. It had undergone a slight
heating, and some of the straw was mouldy. In threshing, the barn was
filled with a fine dust, which tasted and smelled of old straw. I was on
the straw stack all Friday afternoon and the whole of Saturday. About
4 P.M., Saturday, I became very chilly; throat and fauces became sore
and swollen ; a tightness and congested feeling about the chest ; eyes in-
flamed and sensitive ; and severe pains through the head and shoulders
with a feeling of weariness. Following the chill, came on a high fever
with increased pains and throbbing in the head and severe catarrhal symp-
toms. I do not remember of ever passing a more disagreeable night. The
next day (Sunday) had a high fever, with severe pains in head, back and
limbs ; eyes swollen and sensitive, and considerable thin mucous secretion
from the nose and fauces. Towards evening a few blotches made their
appearance on my face. The follov^ang day (Monday) I felt rather better ;
the fever and catarrhal symptoms had partially subsided, and my face and
neck were completely covered with blotches. My father immediately re-
marked that I had measles. This surprised us all, as I had not been exposed
to the disease, there being none in the town where I was attending school,
or in the vicinity. In the coarse of a couple of days, my Avhole body and
limbs were covered with the eruption. The disease passed off' like a case
of ordinary measles, leaving no bad effects, save inflammation of the mucous
membrane of the eyes. This I did not get rid of till the warm weather of
the following spring. In from seven to fourteen days after the eruption
commenced in my case, all my brothers and sisters (seven in number) were
in bed with the genuine measles. My eldest brother attended school with
me, and returned home when I did. These were the only cases of measles
anywhere in the vicinity during that fall and winter. In my attack the
disease commenced with much greater violence than in either of the others.
The fever ran higher and there was greater disturbance about the head,
chest, and throat."

Bearing upon this may be mentioned the circumstance that in almost
every instance, where our soldiers have gone into camp; in a short time
after — the disease — called camj) measles, has made its appearance, without

' For these facts I am indebted to Hon. J. Dille, and tlie Assistant Surgeon Dr.
James Hood.

Salisbury, Effects of Fungi on Human System. [July

any previous exposure — so far as known — to the measles. It should also
be stated that their beds have been usually straw.

At the monthly meeting of the " Farmer^s Club,^^ near Newark, Ohio,
last month, several of the farmers stated to Mr. Dille, that it was quite
common, after threshing wheat, for persons who had been exposed much
to the dust, to be taken with severe chills; followed by a high fever, catar-
rhal symptoms and an eruption on the face. None of them could state,
that any one had ever had the attack twice ; nor whether they had known
any cases to follow the threshing of any other kind of grain than wheat.

It is well known among swine growers, that when they bed their hogs
in straw, they are affected with an eruption in the throat, fauces and roof
of mouth, accompanied with coughing.

Microscopical Examination of the Fungi of Wheat and Rye Straw. —
With these observations before us, we deemed the subject one worthy of a
further and more careful examination ; an examination which would afford
something more positive. With this view, the fungous growths of wheat
straw, and the dust rising from it when disturbed, were carefully examined
under the microscope. The straw used for this purpose was taken from
the beds at Camp Sherman, from Mr. Dille's stable, and from stacks in the
vicinity of Newark. The accompanying drawings (see Plate, Figs. 1 to 14)
represent the plants found — a description of which is given further on.

We then took clean bright wheat straw — free from fungi — packed it
firmly into a box about one foot square and high, wet it with about four
ounces of cold well-water, pressed on and secured the lid, and set the box
near the stove in the ofiBce, where the temperature ranged from 60° to Y5°
Fahr. Twenty-four hours afterwards I opened the box, and found the straw
in the centre of the box heated and covered with a short white mould.
As the straw was stirred, a fine dust of spores and cells were disengaged,
and rose in the air, which, when inhaled, had the odour and taste of old
straw. Examined the fungi under the microscope. The plants were in
all stages of development, from those just starting to those with matured
sporangia.

Again the straw was moistened, the lid secured as before, and left for
forty-eight hours. The box was then opened. Found the mould had ex-
tended wider through the mass and more completely covered the straw.
Submitted the plants to a further careful examination under the micro-
scope. Figs. 15, 16, 17, 18, 19, and 20, are drawings made from fungi
grown in the box.

We further varied the experiments in a variety of ways, and found that
whenever the straw was exposed to a certain temperature, under the influ-
ence of darkness and moisture, fungi were rapidly developed. We also
found that' wheat or rye straw when stacked out or housed, unless unusu-
ally dry, undergoes a greater or less degree of heating, fermentation or

1862.] Salisbury, Effects of Fungi on Human System. 23

decay, during which process a variety of fungi are developed, having the
appearance of mould or mildew on the straw. When this straw is dis-
turbed or agitated in any way the surrounding air becomes filled with innu-
merable spores and cells of the broken and comminuted fungi. The indi-
vidual cells and spores are too minute to be distinguished by the naked eye.
They can only be seen when many are together and the air filled with them ;
then they appear like a thin smoke or fine dust. Suspended in the air
they are freely inhaled, tasting and smelling of old straw. This taste and
smell is often quite persistent, lasting for hours. The air may be filled
with them though invisible to us ; but generally their presence can be dis-
covered by the taste and smell. These cells and spores are shown in Plate,
Figs. 1, 2,' 3, 4, 9, 18, and 19. Those represented at Figs. 1, 18, and 19,
make up by far the larger proportion. They are oval, and often several
are attached to each other in a line, in the direction of their longest dia-
meter. Figs. 2 and 9 represent spherical spores, much larger than those
of Fig. 1, and united generally in masses instead of lines. Figs. 8 and 4
represent large oval spores. Figs. 5 and 6 represent sporangia, which pro-
duce the large oval spores 8 and 4. Fig. 6 appears to be a partially broken
down sporangium. The plants are of a dull yellowish brown colour ; the
sporangia of a light greenish yellow w^hite. Fig. a plant which pro-
duces the spherical spores 2 and 9. It has four sporangia — two nearly
mature and ready to shed their spores and two in process of development.
The stems or mycelia of these plants are of a yellowish snuff colour; the
sporangia are of a light greenish yellow white. Figs. 8 and 10 represent
plants that produce spores like those of Fig. The colour of the mycelia
and sporangia are also the same ; yet the arrangement of the sporangia
on the mycelia seems to differ and may represent a different species. Figs.
11 and 12 are plants with oval or egg-shaped sporangia, wdiich do not
exceed one-thirtieth the size of those of 8 and 10. Their colour is an
orange brown ; the mycelia are lighter. In this species, there is one main
stem or mycelium with numerous branches, each bearing one or more spore
cases. The branches are mostly made up of a single row of oval cells, like
Fig. 1, attached end to end. Fig. 14 represents a plant from the sprout
of a wheat kernel. The sporangia are small and nearly spherical. In this
species there is a main stem with numerous short branches of nearly equal
length, each terminated with a single spore case. The plants are of a light
yellowish white colour. This species, or one similar to it, wdth generally
shorter branches, is very common on the straw. Fig. 13 represents plants
from the sprout of a wheat kernel. The whole plant appears to be dicho-
tomous; colour, light greenish white. The sporangia are peculiar, being
shaped like a tassel, with radiating lines of cells, attached to each other
in the direction of their longest diameter, standing upon oval basidia.
Fig. IT, plants from a straw that "was cut before it had matured. The

Salisbury, Effects of Fangi on Human System. [July

plants are white with a yellowish tint. Each plant consists of a single
branchless mycelium terminated by a small oval sporangium.

Figs. 14, 15, and 16, are the plants which are by far the most common
on the mature straw. They are very prolific ; maturing in from twelve to
twenty-four hours under favourable circumstances ; having the appearance,
to the naked eye, of short white mould or mildew, completely coating the
stems. When the straw is agitated, the air is filled with thin minute
elongated cells and spores. Figs. 1, 18, 19. These plants consist of a main
stem — made up of interlacing cells — from which proceed numerous short
branches (made up generally of a single line of cells), each one of which is
either terminated by a small spherical sporangium or an enlarged cell. The
plants Figs. 14, 15, and 16, are mingled together and are probably the same
species. The branches of 14 and 15 are terminated with sporangia, while
those of 16 are terminated simply by slightly enlarged cells. The plant
Fig. 12, in frequency, ranks next to 14, 15, and 16, and is interspersed with
them on the straw. When straw that is covered with these plants is
slightly or carefully agitated, the cells and spores which are set at liberty
and float in the air, are but little aggregated, as seen in Fig. 18. If the
straw is agitated violently as in pitching it, the cells and spores set at
liberty are more or less aggregated in masses and lines and mingled with
them are the sporangia of plants Fig. 12 ; see Fig. 19. Fig. 20 is a peculiar
white fungus, with a light straw tint, which occasionally is met with on the
straw. It is, however, not common. The fungi, Figs. 5, 1, 8, and 10, we
found generally on straw that had undergone further decomposition than
that on which the others were met with.

Inoculation of the Human System ivitJi the Spores and Cells of the
Fungi of Wheat and Rye Straw. — Case I. At 10 o'clock P. M., Feb-
ruary 11th, 1862, 1 inoculated my arm with the spores and cells of the fungi
of wheat straw, which I obtained by placing a straw — covered with the
plants — on a plate of glass, and hitting it with a few slight taps. On
removing the straw, under and both sides of it was a white cloudy band,
about ^ of an inch wide, running across the glass. These spores and cells
lay so thick on the glass, that, to the naked eye, they seemed to touch each
other. Their appearance under the microscope is represented in Fig. 1.
The straw from which I obtained these cells came from a stack near this
place, and was the same kind of straw as that used for beds at the camp.
Under the microscope the fungi presented the same appearance, and the
cells disengaged in agitating the straw were precisely similar.

Wednesday, Feb. 12th, perfectly well. No inflammation or itching
around the point of inoculation.

13//?. Slight nausea. A very slight redness and itching at inoculating
point.

14//?. Got up with a feeling of lassitude and nausea, which continued all
day. The redness and itching of inoculating wound increasing ; had diffi-
culty in keeping warm ; chilly all day ; occasional sneezing ; eyes sensitive;'
liad a peculiar feeling about the scalp, as if red pepper or mustard had been
rubbed into the pores.

1862.] Salisbury, Effects of Fungi on Human System. 25

Saturday, Feb. 15. Nausea and lassitude continue ; occasional sneezing ;
flashes of heat over the whole body ; itching and inflammation of the
wound on the arm increasing ; thoughtlessly rubbed ofl' the scab, which was
about three lines in diameter. The peculiar smarting, burning, congested
sensation over the whole scalp, has increased since yesterday. It extends
into the bone, with pains through the forehead and temples. A few blotches
have made their appearance on the face and neck. Eyes weak and inflamed,
so much so that I could not use them to read over half an hour during the
evening. A heavy oppressive feeling about the chest ; mucous membrane
of fauces and throat dry and irritated ; feel as if I had a severe cold.

Sunday, Feb. 16. Had a sensation of weariness and drowsiness, with
nausea, all day. Eyes red, inflamed, and sensitive ; smart, so that I can-
not use them to read by gaslight. Whole scalp feels sore, with a constant,
congested, burning sensation all through it to the bone. Arm itches ; red-
ness as large as a dime. A heavy congested feeling about the chest ; have
had more or less fever since Saturday morning. Throat and fauces dry and
swollen, and voice hoarse. Pains in back and head have been almost con-
stant since Friday last.

Monday, Feb. 17th. The burning sensation of the scalp still continues.
Eyes weak and inflamed ; cannot use them long at a time, without pain.
There is still slight fever and nausea.

Tuesday, Feb. 18th. Nausea ; face feels as if it had been exposed to the
heat of an open fire till it had become inflamed. The peculiar burning
soreness of the scalp is somewhat relieved. Eyes still sensitive ; catarrhal
symptoms and fever less than yesterday.

Wednesday, Feb. 19th. Yery much better; the soreness of scalp almost
entirely relieved ; blotches and redness of face disappeared ; catarrhal symp-
toms and fever gone ; eyes quite well.

Case II. Wednesday Evening, Feb. 19th. Inoculated myself again in
the same place, with the spores and cells of fungi as before.

Thursday, Feb. 20th. Feel perfectly well, except a slight sensitiveness of
the eyes.

Friday, Feb. 2 1st. Same as yesterday.

Sunday, March 2d. Have felt perfectly well since Feb. 21st. Eyes com-
pletely recovered.

Monday, March 3d. The last inoculation has produced no effect upon the
system, that I can discover.

Case III. Wednesday Evening, Feb. 19, 1862, inoculated my wife on
her arm, with the spores and cells of the straw fungi. The cells were taken
from the same group as those used in the second inoculation of my own
arm, on the same evening.

Thursday, Feb. 20th. Perfectly well all day.

Friday, Feb. 21st. During the day, a dry constricting feeling of the
throat made its appearance, and grew much worse during the following
night. Voice hoarse ; has felt chilly through the day, with a feeling of
lassitude and drowsiness. Nausea; ate no dinner. Throat and fauces in-
flamed.

Saturday, Feb. 22d. Nausea ; but little appetite ; severe pains through
the forehead and temples ; tongue considerably furred ; throat feels dry
and inflamed, with a very disagreeable constricting feeling, as if it would
close up. A tumid appearance of fauces ; voice hoarse ; slight fever.

Salisbury, Effects of Fungi on Human System.

[July

Sunday, Feb. 23d. All through last night her throat felt as if it would
close up. Rest very much disturbed. In the morning, throat felt better.
Occasional sneezing ; voice hoarse ; some pain in swallowing. Stupid,
weary, and inclined to sleep.

Monday, Feb, 24th. Throat did not trouble her much last night; still
hoarse ; head stopped up, as if with a cold ; towards evening a fulness and
throbbing about the head, which felt sore.

Tuesday, Feb. 25th. Had rather a restless night; head feels sore, swol-
len, and heavy, as with a severe cold; eyes sensitive; catarrhal symptoms
severe ; heaviness about the chest ; slight cough ; considerable lassitude and
drowsiness; slept from 10 A.M. till 3 P. M. ; but little appetite. Had
through the day occasional sensations of deafness ; slight redness in spots
under the skin on the face. During the evening the pains in the head were
relieved, and bowels became tender and sore.

Wednesday, Feb. 26th. Had a good night's rest ; head relieved ; eyes
still sensitive ; catarrhal symptoms subsiding ; chest feels easier ; bowels
very sore and tender to the touch. Appetite returning ; redness on arm
nearly gone ; slight itching yet.

Thursday, Feb. 2Hh. Rapidly recovering ; head and eyes feel quite well ;
bowels still slightly tender.

Friday, July 28th, quite well.

It will be seen from this case, that although there was scarcely any per-
ceptible blotches, yet the other symptoms, such as chills, followed by fever,
pains in the head, catarrhal symptoms, nausea, lassitude, &c., were all
present. The disease commenced in the head, throat, and fauces, and
passed downward, the bowels being very sore after the head, throat, and
chest were relieved.

Case IY. On Sunday, March 23d, 1862, Chas. B. Pierce, a fine healthy
boy, six years of age, was exposed to measles, by contact with the disease.

March 26th, seventy-two hours after the exposure, inoculated him with
the fungi of wheat straw. The fungi were grown in my office, and shaken
off from the straw on plates of glass, between which the spores and cells were
preserved for use. On the second day after the inoculation (March 28th),
a redness appeared around the inoculating point, about the size of a dime.
This was preceded and accompanied by catarrhal symptoms resembling a
slight cold. Did not complain. Played out of doors every day. This
redness at the point of inoculation soon disappeared ; the catarrhal symp-
toms subsided, leaving no bad effects ; and on April 2d, he was perfectly
well. Forty -two days have passed since this boy was exposed to the dis-
ease, and there are no signs of measles yet.

Cases Y. to IX. Mr. Bartholomew, of Newark, Ohio, has a family of
seven children, ranging from three to seventeen years of age. On Wednes-
day morning, April 2d, Franklin Bartholomew, the next to the oldest son,
broke out with measles. On Saturday evening, April 5th, three days after
Franklin came down with the disease, and three days after the exposure of
the entire family, I was called upon by Dr. Teller, their family physician,
to go with him and inoculate the other six children and the mother, none
of whom had ever had the disease. We inoculated the mother, and four
of the children, leaving two boys — one thirteen and the other seventeen

1862.]

Salisbury, Effects of Fungi on Human System.

years of age — without being inoculated. On April 14th, the boy seventeen
years of age, and on April 16th, the one thirteen years of age broke out
with the disease. It has now been five weeks since the exposure of the
mother and the four children inoculated. Although there has been three
successive cases of measles in the house, none of those inoculated have had
any symptoms of the disease. From twenty-four to thirty-six hours after
the inobulation, !hey all had symptoms, resembling a slight cold, with a
little chilliness, catarrhal symptoms and sneezing. Beyond this they have
been perfectly well from the date of the inoculation to the time of this
writing. May 5th.

The inoculation does not produce a pustule and scab, like the vaccine
virus, but simply a redness, around the wound, like a measle blotch. There
is seldom any soreness, but usually a simple itching sensation for two or
three days, extending generally from the second or third to the fifth or
sixth day after the inoculation.

Cases X. to XIII. April 12th, inoculated with rye straw fungus

Mrs. , and two of her children, none of whom had ever had measles,

and who had been exposed to the contagion of the disease from a case of
genuine measles in the family, which broke out April 6th. On the evening
of the 13th and morning of the 14th, they all had symptoms of chilliness
followed by fever, catarrhal symptoms, slight cough and sneezing. The
inoculating wound became red over a surface about the size of a dime, pre-
senting the appearance of a measle blotch.

Their symptoms were so slight that the children were not kept in doors,
and the mother was not prevented from attending to her ordinary duties.

On the 18th they had all quite recovered. It is now four weeks since
the exposure, and no signs of measles in any of the cases inoculated.

From the inoculations as far as they have gone, in from twenty -four to
seventy-two hours, the effects begin to show themselves in lassitude, chilli-
ness, catarrhal symptoms and pains through the forehead and temples. It
is highly desirable that these experiments should be extended further. For
this reason we publish thus early our observations and experiments (much
more limited than we could have desired, on account of the difficulty in
this place of obtaining subjects who are willing to sacrifice a few hours'
health to such purposes) that others in larger places, who have greater
facilities in the way of hospitals, &c., for carrying out more extended series
of experiments under the eye of the attending physicians, may take up
the matter and aid in its further investigation.

I have not been able to distinguish thus far any difference between the
eruption and attendant symptoms of genuine measles and "camp measles,"
or straw measles. When the disease is communicated to the human sub-
ject, however, by inhaling the spores and cells of straw fungi, the eruption
appears to follow the exposure or inhalation in from twenty-four to ninety-
six hours. While in exposures to the contagion of the disease, the erup-
tion does not usually make its appearance until from eleven to fourteen days
thereafter. It is stated that in inoculations made by using matter obtained

Salisbury, Effects of Fungi on Human System.

[July

from the measle blotch, or by using the tears, blood, or salivary secretions
of subjects broken out with the disease, the modified type of measles which
results makes its appearance generally on the sixth or seventh day after
the inoculation. In inoculating, however, with the spores and cells of
straw fungi, the symptoms commence usually in about twenty-four hours;
though sometimes they do not make their appearance till as late as seventy-
two hours thereafter.

This matter, however, requires further investigation before fully reliable
statements can be made.

To what extent inoculation with straw fungi may prove effectual in pro-
tecting the human system against the contagion of measles can only be
settled by careful and extended experiments.

In Wood's Practice, under the head of Causes of Measles, we find the
following statements, which we here quote, as they point indirectly to a
possible origin of the disease somewhere in the direction of the results of
these examinations.

''Though capable of being propagated by contagion, measles prevail much
more at some periods than at others ; probably under a peculiar epidemic influ-
ence. Whether this influence is sufficient of itself to produce the disease ; or
whether it merely acts by increasing the susceptibility to the contagious princi-
ple, may perhaps be considered uncertain. If the fact quoted by Eayer from
an old author, that the disease was not known in the new world until the year
1518/ when it was imported from Europe, could be relied on, it would go far to
prove that epidemic influence is alone insufiicient ; but the testimony can hardly
be admitted to have much weight; and the very frequent occurrence of the dis-
ease without any possibility of tracing the cause to personal communiccdion,
ivould lead to the opposite conclusion} Still there is no impossibility in the
production at once by the human body and by other unknown agencies in na-
ture, of the same identical poison, whatever that may be. . The difficulty would
be removed one step by admitting the vital organic character of contagions.
Cold iveather^ appears favourable to the production of the disease, as epidemics
of it are most frequent in winter. They occur, however, at all seasons. No
age is exempt from the disease. It attacks the foetus in the womb and old per-
sons in their second childhood. Yet it is much more freciuent in children than
in adults. One reason of this may be a diminished susceptibility ; yet a much
stronger one is the fact, that most persons have the disease in early life, and can
have it but once. There is a general susceptibility to measles ; and there are
very few who are not attacked at one or another period of their lives.

" Though, as a general rule, measles are capable of being taken but once, in-
stances have undoubtedly occurred, as in all other contagious diseases, in which
the same individual has been affected a second- time."

* Wheat and the other small grains were introduced into the new world about
this time. Having no straw to generate the fungoid cause, they probably did not
have the disease.

2 It would, if there existed in the new world the proper material from which the
cause or contagion emanates. If this be confined to the straw of our cereal grains
and these were not known here previous to 1518, then there is a probability that
the author, whom Rayer quotes from, may be correct.

Wheat and the other small grains are generally threshed during the fall and .
winter, and these are the seasons when the straw is the most used, and the periods
when the disease usually occurs. When it occurs at other seasons, it is highly
probable it may originate from straw beds.

1862.]

Flint, Cardiac Murmurs.

Art. II. — On Cardiac 3Turmiirs. By Austin Flint, M.D., Prof, of
the Principles and Practice of Medicine in the Bellevue Hospital Medical
College, N. Y., and in the Long Island College Hospital.

The clinical study of cardiac murmurs, within the last few years, has led
to our present knowledge of the diagnosis of valvular lesions of the heart.
By means of the organic murmurs it is positively ascertained that lesions
exist in cases in which, without taking cognizance of the murmurs, the
existence of lesions could only be guessed at. The absence of the organic
murmurs, on the other hand, enables us generally to conclude with positive-
ness that valvular lesions do not exist. As a rule, to which there are but
few exceptions, these lesions may be excluded, if there be no murmur.
These are great results ; but the practical auscultator of the present day
need not be told that the clinical study of cardiac murmurs has led still
further into the mysteries of diagnosis. Having ascertained the different
murmurs which occur in connection with valvular lesions ; having traced
their connection, respectively, with different lesions ; having shown their
relations to the movements of the several portions of the heart, and to the
cardiac sounds-/ and, having explained satisfactorily the mechanism of
their production, we are able to determine not only the existence or non-
existence of valvular lesions, but their particular situation when they are
present, and, to a certain extent, their character and consequences. The
practiced auscultator, by listening to the murmurs alone, is able to tell
whether lesions are situated at the mitral, or the aortic, or the pulmonic
orifice, and he is able to say, in certain cases, that the valves which are to
protect these orifices against a regurgitant current of blood, have been
rendered by disease inadequate to their office. It is unnecessary to adduce
proof of these statements ; their correctness is sufficiently known to those
who are conversant with physical exploration as applied to the diagnosis
of afi'ections of the heart. How strikingly do these facts exemplify the
progress of practical medicine to those who, although still among the
junior members of the jDrofession, have practised before and since the recent
-developments in this department of our knowledge !

These remarks are introductory to the consideration of various practical
points pertaining to the cardiac murmurs. And the first subject will relate
to these murmurs in general — viz., the limitations of their significance.
After having considered certain points embraced in this subject, I propose
to take up various points relating to the different murmurs separately.

' The conventional distinction between the cardiac sounds and murmurs is to be
borne in mind ; t}ie former term being limited to the normal heart-sounds with
their abnormal modifications, and the latter to newlj-developed or adventitious
sounds, which are altogether the products of disease.

Flint, Cardiac Murmurs.

By the limitations of the significance of the murmurs, I mean the actual
amount of knowledge respecting valvular lesions to be derived from this
source. It is evident, from what has been stated already, that the know-
ledge which they convey is of very great importance, but, important as this
knowledge is, it has certain limits which are not always sufficiently under-
stood ; and, as a consequence, the practitioner is liable to fall into unfor-
tunate errors of opinion as regards the gravity of the lesions which the
murmurs represent.

Prior to the clinical study of the cardiac murmurs, the existence of or-
ganic affections of the heart was recognized when, in conjunction with
disturbed action of the organ, symptomatic events had taken place which
belong to an advanced stage of only a certain proportion of cases. Dys-
pnoea, palpitation, and dropsy, were the symptoms mainly relied upon for
the diagnosis. The recognized cases were then comparatively rare, and,
when recognized, a speedily fatal issue was expected. This fact, together
with the frequency with which cardiac lesions were revealed by post-mortem
examinations in cases of sudden death, rendered the diagnosis of organic
disease of the heart equivalent to a summons from the grave. The prog-
nosis, as a matter of course, was as unfavourable as possible ; the doom of
the patient was either to die unexpectedly at any moment, or to endure
protracted sufferings until released by death. The study of the murmurs,
together with the application of other signs, enabled the practitioner to
recognize organic affections at a period in the disease when otherwise they
would not have been discovered. The recognized cases became more fre-
quent. Persons were found to have cardiac lesions who presented few or
no symptoms pointing obviously to disease of the heart. The ideas which
had prevailed relative to the gravity of organic affections, however, natu-
rally enough, continued to prevail. An organic murmur, consequently,
had a fearful significance. It was considered as proof of disease which was
not less surely destructive because earlier ascertained. Let it be said of a
patient that he had a cardiac murmur denoting a valvular lesion, and his
doom was pronounced; sudden death, which might occur at any time, or
an early development of the distressing symptoms characteristic of cardiac
disease, were to be expected, whatever might be his present condition.

So far from concealing from patients the fearful significance of cardiac
murmurs, it was considered important for them to understand fully their
precarious condition, in order to receive their co-operation in the measures
of management which were deemed essential. These measures embraced
general and local bloodletting, depletion by cathartics, sedative remedies
addressed to the circulation, mercurialization, low diet, together with as
much inaction of mind and body as possible. The consequences of this
management were calamitous in the extreme. In fact, these measures'
contributed, in no small degree, to the fulfilment of the gloomy predictions
impressed upon the minds of the unfortunate patients who were found to

1862.]

Flint, Cardiac Murmurs.

present the auscultatory sign of valvular lesions. So long as these notions
with regard to the treatment of cardiac affections prevailed, an early diag-
nosis, instead of being desirable, was a serious disadvantage, and truly
fortunate were they who kept aloof from the stethoscope of the auscultator !

Erroneous views respecting the significance of cardiac murmurs, and also
respecting the indications for treatment in cases of organic disease of the
heart, are still, to a greater or less extent, prevalent. I propose now to
confine myself to the former, i. e., the significance of the murmurs. It is
obvious that with the acquirement of means of ascertaining the existence
of lesions at an early period, when, without these means, the lesions could
not have been discovered, clinical experience had to take a new point of
departure as regards prognosis. And experience has shown that lesions
giving rise to cardiac murmurs by no means invariably denote impending
danger or serious evils, and that they are not unfrequently innocuous.
Several clinical observers, within the last few years, have contributed facts
going to show the correctness of this statement. Of these. Dr. Stokes' is
especially prominent. Dr. Gairdner, of Edinburgh, has lately communicated
a valuable paper on this subject.^ I have been able to gather some facts
having an important bearing on the subject under consideration. Of the
cases which have come under my observation, exemplifying the ''limitations
of the significance of cardiac murmurs," I shall select a few of the most
striking.

Thirteen years ago, I attended a child, aged 11 years, with a slight
rheumatic attack. Directing attention to the heart, I found a very loud
mitral, regurgitant murmur, heard over the left lateral surface of the chest
and on the back. The heart was enlarged, the extent and degree of dulness
in the pr^cordia being increased, and the apex beat without the nipple.
The murmur was evidently not due to an endocarditis developed during the
present attack of rheumatism ; the lesion giving rise to it probably origi-
nated in an obscure thoracic affection which had occurred seven years before.
I was at that time less acquainted with the significance of cardiac murmurs
than now, and I deemed it my duty to inform the mother of the patient of
the existence of an organic affection of the heart, which would be likely to
destroy life within a period not very remote. The patient is still living.
She is now 24 years of age, and, although presenting a delicate appearance,
a casual observer would not suspect the existence of any disease. She is
suliject to palpitation, to coldness of the extremities, and experiences want
of breath on active exercise, but she does not consider herself an invalid,
and the apprehensions caused by my communication . to the mother have
long since disappeared.

It is fair to presume that my opinion in this case was considered as a
mistake. It was, indeed, an error of judgment as regards the prognosis,
but the diagnosis was correct ; the loud bellows murmur is still there, and

' Diseases of tlie Heart and Aorta.

2 Edinburgh Monthly Journal of Med. Science.

Flint, Cardiac Murmurs.

[Jnly

heard over the whole chest, even through the dress, and the heart is con-
siderably enlarged. The patient, if not destroyed by some intercurrent
affection, will ultimately die of cardiac disease, yet it is now twenty years
since the probable commencement of the lesions giving rise to the cardiac
murmur.

Nearly twenty years ago a person was examined by a medical friend with
reference to an assurance on his life. My friend, finding a loud murmur,
and an abnormally strong action of the heart, brought the person to me as
an interesting case for examination. I failed to record the case, and am
not therefore positive as regards the particular murmur present, but I think
it was the mitral regurgitant. Since that examination, until recently, I
have been in the habit of meeting this person often, although he has never
been my patient. He has been, and still is engaged in active business. He
is now about fifty years of age. He has survived his wife, and been again
married within a few years.

I have selected these two cases as illustrating the duration of' life and
comfortable health for thirteen and twenty years after a loud organic mur-
mur, together with enlargement of the heart, had been ascertained ; in both
cases life and comfortable health continuing at the present moment, I
could cite, in addition, numerous cases of persons now living, and appa-
rently well, who have had organic murmurs for several years. In making
examinations of chests, supposed to be healthy, for purposes of study, I
have repeatedly found a murmur, evidently organic, when no disease of the
heart was suspected either before or after my examination. The following
case is instructive, as showing the Importance of taking into account the
coexistence of functional disorder of the heart, dependent on anemia, with
organic disease.

In November, 1852, I visited, in consultation with Professor Kogers, of
Louisville, a lady aged about 25. She had had repeated attacks of acute
rheumatism. She had an infant several months old, which she was nursing,
and she had become quite ansemic. She had begun to suffer from palpitation
during the preceding summer, and her attention was attracted to a sound
in the chest which she heard in the night-time. This sound was also heard
by a sister with whom she slept. She described, of her own accord, the
sound to be like that produced by a pair of bellows. She had never heard
of cardiac bellows-murmurs, and at this time there had been no examination
of the chest. Prof. Rogers had been called to the patient a short time
before my visit, and detected at once the existence of organic disease.

She presented an aortic direct and a mitral regurgitant murmur, both
loud ; the heart was moderately enlarged, and its action violent. She was
conscious of this violent action, and slight exercise or mental excitement
occasioned much distress from palpitation. The urgent symptoms in the
case were attributed to anaemia ; weaning was at once enjoined, and chaly-
beate remedies, etc., advised. I met the patient a year afterwards without
recognizing her. She was apparently in perfect health, and presented a
blooming appearance. Her friends thought we must have been mistaken
in our opinion as to the existence of organic disease of the heart. The
murmurs and the signs of enlargement, however, were still there. She

1862.] Flint, Cardiac Murmurs. 33

continued to enjoy good health until the summer of 1856, when she suffered
from uterine hemorrhage, and again became ansemic. The action of the
heart became irregular, and she complained much of vertigo. Tonics,
stimulants, nutritious diet and fresh air failed to remove the anaemic state,
and at length she was seized with apoplexy and hemiplegia. She recovered
from the apoplexy, but the hemiplegia continued, and death took place
between two and three weeks after the apoplectic seizure.

The significance of organic murmurs is limited to the points of informa-
tion already stated in the introductory remarks, viz., the existence of lesions,
their localization, and the fact of valvular insufficiency or regurgitation.
Whether the lesions involve immediate danger to life, or, on the contrary,
are compatible with many years of comfortable health, the murmurs do
not inform us, nor do they teach us how far existing symptoms are referable
to the lesions, and how far to functional disorder induced by other morbid
conditions. Neither the intensity nor the quality of sound in the murmurs
furnish any criteria by which the gravity of the lesions or their innocuous-
ness can be determined. A loud murmur is even more likely to be pro-
duced in connection with comparatively unimportant lesions than with
those of a grave character, because in the former, rather than in the latter
case, is the action of the heart likely to be strong, and the intensity of the
murmur, other things being equal, will depend on the force with which the
currents of blood are moved. Whether the murmur be soft, or rough, or
musical, depends not on the amount of damage which the lesions have
occasioned, but on physical circumstances alike consistent with trivial and
grave affections.

It may be imagined that these assertions, although true as regards
murmurs produced by the direct currents of blood, do not hold good with
respect to the regurgitant murmurs. The latter, it may be said, involving
as they do insufficiency of the valves, will be loud in proportion to the
amount of blood which regurgitates, and, therefore, the intensity of the
murmur should be a criterion of the amount of valvular insufficiency.
But clinical observation disproves this surmise. A minute regurgitant
stream is as likely to be intensely murmuring as a large current, perhaps
even more so. Here, too,, the loudness of the sound will depend, in a great
m.easure, on the power of the heart's action. To this point I shall recur
when I come to consider the different murmurs separately.

The practical injunction to be enforced in connection with the limitatioas
of the significance of the cardiac murmurs is^ that we are not to j;Udge of
the magnitude of valvular lesions, of the amount of danger on the one
hand, or of the absence of danger on the other liand, by the characters
Monging to the murmurs. The physician who undertakes to interrogate
the heart by auscultation is not to decide that the condition of his patient
is alarming, simply because he finds a murmur which he satisfies himself is
dependent on an organic lesion of some kind. The lesion may be at that
Ko. LXXXYII.— July 1862, S

34 Flint, Cardiac Murmurs. [July

time, and perhaps ever afterwards, innocuous ; the evils arising from cardiac
affections maybe remote, and so far from plunging the patient into despair
by the announcement of the fact that he has an incurable disease of heart,
there may be just grounds for holding out expectations of life and com-
fortable-health for an indefinite period. Neither does it necessarily alter
the case when more than one murmur is discovered ; the existence of several
murmurs by no means excludes the possibility of similar encouragement.
We are to look to other sources of information than the murmurs in forming
an opinion respecting the gravity of the affection. What are the sources
of information on which our opinion is to be based ? It does not fall
within the scope of this essay to consider at length the points involved in
the answer to this inquiry. I shall answer it in a few words.

The heart-sounds furnish means of determining whether the lesions are
of a nature to affect materially the function of the valves. I must here
pass by this useful and beautiful application of auscultation with a simple
allusion to it, referring the reader • elsewhere for a full exposition of the
subject.* I shall, however, return to the subject presently in considering
the murmurs individually. Means requiring less proficiency in physical
exploration relate to enlargement of the heart. It is not a difficult problem
to determine whether the heart be or be not enlarged, and it is easy to
determine the degree of enlargement. Now, in general, if valvular lesions
have not led to enlargement of the heart, they are not immediately
dangerous, and the danger is more or less remote. Here is a criterion of
great importance in estimating the gravity, on the one hand, or the present
innocuousness on the other hand, of lesions giving rise to murmurs. So
long as the heart be not enlarged, the lesions cannot have occasioned to
much extent those disturbances which arise from contraction or patency
of the orifices. The murmurs, in themselves, give no information respect-
ing the amount of obstruction from contracted orifices, or of regurgitation
from valvular insufficiency. Let this fact be constantly borne in mind.
But obstruction and regurgitation singly or combined, inevitably lead to
enlargement of the heart ; hence the latter becomes evidence of the former.
The degree of enlargement is, in general, a guide to the extent and duration
of the disturbances occasioned by contracted and patescent orifices. As a
rule, if the heart be slightly or moderately enlarged, the immediate danger
from the lesions which may give rise to one or more loud murmurs is not
great.

The truth is, the evils and danger arising from valvular lesions, for the
most part, are not dependent directly on these lesions, but on the enlarge-
ment of the heart resulting from the lesions. We may go a step further
than this and say that, ordinarily, serious consequences of valvular lesions

' Clinical Study of the Heart-sounds in Health and Disease, Prize Essay, Trans.
.Amer. Med. Association, 185y.

1862.] Flint, Cardiac Murmurs. 35

do not follow until the heart becomes weakened either by dilatation or by
degenerative changes of tissue. So long as the enlargement be due mainly
to hypertrophy of the muscular walls, the patient is comparatively safe.
Hypertrophy is a compensatory provision, the augmented power of the
heart's action enabling the organ to carry on the circulation in spite of the
disturbance due to obstruction and regurgitation. Happily, in most cases,
hypertrophy is the first effect of valvular lesions, and, for a time, it keeps
pace with the progress of the latter. Dilatation, which weakens the
heart's action, is an effect consecutive to hypertrophy, and, as a rule, it is
not until the dilatation predominates that distressing and dangerous evils
are manifested..

The practical bearing of these views respecting hypertrophy and dilata-
tion, on the management of organic affections of the heart, is obvious.
They are inconsistent with the employment of measures to prevent or
diminish hypertrophy ; on the contrary, they point to the importance of
an opposite end of management, viz., to encourage hypertrophy in prefer-
ence to dilatation, and to maintain the vigour of the heart's action. It
does not fall within the scope of this essay to consider therapeutical appli-
cations, and I must content myself with this passing notice of an immensely
important reform in the management of organic affections of the heart.

Returning to the means of determining the gravity of valvular lesions,
I repeat, they become serious, in other words, the distressing and dangerous
symptomatic events are to be expected, in proportion as hypertrophy
merges into dilatation, or as weakness of the organ may be induced by
structural degeneration or other causes. In connection, then, with murmurs,
we are to determine the condition of the heart as respects the points just
mentioned, in order to estimate properly the gravity of the lesions which
the murmurs represent. In leaving this subject, viz., the limited signifi-
cance of the cardiac murmurs, I will give a case which is a type of a class
of cases not unfrequently coming under observation.

In the spring of 1860, I was consulted by a medical gentleman from a
distant State, who furnished me with the following written statement of
his case : —

" About a year ago I went to the city of to place myself under the care

of Dr. , for a trifling surgical difficulty with which I had been annoyed for

a long time. At long intervals previous to that time I had had severe pains in
the left breast about the cardiac region, but at no time from any coustant pain.

I thought the pain was of a neuralgic character. While at • I thought I

would have my lungs examined, as some members of my family had been con-
sumptive. I went to Dr. and to Dr. , both of whom pronounced my

lungs sound, but said that my heart was affected. I came home much depressed
by their opinion, and suffered so much from mental anxiety that in the course of
a month or two I determined to go back and consult another medical gentleman.

Dr. . He told me there was some roughness about the sounds of the heart

but no serious organic disease. I was much relieved by this opinion, and clung
to the belief that the pains were of a neuralgic character.' Previous to my

' Doubtless thej were so.

Flint, Cardiac Murmurs.

[July

going to I had all my life taken a good deal of out-door exercise, such as

riding, hunting, fishing, etc., for the purpose of warding off any tendency to
consumption. I have always had a frail figure and been inclined to despondency.
I have suffered a great deal of anxiety, owing to family afiairs and business

matters. After my return from consulting Dr. I thought it best to give up

active exercise for fear of increasing any cardiac affection that might exist. I
do not think that I have had any severe pain in my chest frequently, at
any time, but only at intervals and apparently occasioned by anxiety about
patients, etc.

"In December last I went into the country, 13 miles, to see a patient. The
weather was very cold, rainy, and windy ; I returned in the night. I was suffer-
ing from toothache and smoked a cigar in order to relieve the pain. I went
over to my office to write a prescription for a sick child, and on my way back I
was attacked with palpitation of the heart for the first time in my life. I came
into the house and lay down, when I was seized with severe rigors without
chills. I had also pain in the back and afterwards fever. Since then I have
been subject, at intervals, to a jarring or knocking sensation about the heart,
but no palpitation of long continuance. I cannot sleep as well on my left side
as formerly, as it causes an uneasy sensation with something like palpitation
and some pain. I do not take much exercise, and find that I get out of breath
easily. I am very sensitive to cold. The attacks of increased action of the
heart are always accompanied by rigors and irritability of the bladder. On the
19th of March, I was taken with a feeling of fatigue and indigestion, followed
by severe rigors together with great heat of the head and body. The circula-'
tion was rapid and accompanied by palpitation. The attack lasted nearly an
hour, and I feel the effect of it to-day, March 22d. I notice, when reading a
newspaper or small book, that the action of the heart causes it to vibrate.
During my first attack in Dec, I had an intermittent pulse. I did not recover
from that attack so as to go out for a week, and have not since been as well as
before.

"Fearing that my situation was critical I have been careful of myself. I
have feared to increase the affection and that I might die suddenly. But I have
had fear that in taking care of the cardiac affection I shall increase a tendency
to consumption. Any mental anxiety increases the action of the heart. I do
not smoke nor chew tobacco, nor drink any alcoholic liquors. I have suffered
much from toothache ; in other respects have had generally very good health.
I have never had rheumatism. I am a married man with five children. I think
my cardiac affection has been getting worse since December last, and I suffer in
mind dreadfully on that account, as I have a great deal to live for."

On examination of the chest, in this case, I found the apex-beat in the
5th intercostal space half an inch within a vertical line passing through
the nipple. The area of superficial cardiac dulness carefully delineated on
the chest, was found to be of normal extent. The left border of the heart
fell within the nipple. The respiratory murmur, on a deep inspiration,
was heard over the whole pr^ecordia. The apex-beat was not abnormally
strong ; no other impulse was discovered, and no heaving of the prtecordia.

At the first examination, the heart being but little excited, I discovered a
slight murmur just to the left of the apex, heard only during the latter
part of each inspiratory act. T could discover no murmur at the base. At
a subsequent examination on the same day, made after dinner, the patient
having drank a little wine with his dinner, the action of the heart was
much greater than at the previous examination. I then discovered a well-
marked systolic murmur at the apex, to the left of the apex and at the
lower angle of the scapula ; I also ascertained the existence of a soft sys-
tolic murmur at the base on the left side of the sternum and not on the
right side. This murmur extended over the whole summit of the chest on
the left side. At the summit it came evidently from the subclavian, as the

1862.-]

Flint, Cardiac Murmurs.

pitch differed from that of the murmur over the pulmonary artery, i. e., in
the 2d intercostal space on the left side.

On the next morning I made an examination while the patient was still
in bed. The heart was then acting tranquilly. I discovered a feeble
murmur at the apex only ; this murmur was not perceived behind, and no
murmur was heard at the base.

The aortic and pulmonic second sounds were normal, and so also were
the mitral and tricuspid valvular elements of the first sound.

I shall quote from my record book the remarks which were appended to
this case when the record was made : —

"The heart is but little if at all enlarged, and the heart sounds are normal.
There exist, therefore, no lesions which at present are of serious import.
Tlie cardiac trouble which has occasioned the patient so much unhappiness
and anxiety, is purely functional.

"Dr. (who first examined this patient) evidently discovered a

murmur. His examination was not very critical, and was made after the
patient had just mounted stairs at his hotel. The opinion that there was
organic disease without any qualifying explanations produced a profound

moral impression on the patient. The opinion of Dr. ■ subsequently

did something toward relieving the apprehensions of the patient ; but his
coming such a long distance to consult me is evidence how much his mind
was ill at ease on the subject."

" The heart is not entirely free from lesions ; there is slight mitral regur-
gitation. The murmur at the base is perhaps inorganic, or at all events
it does not denote important valvular lesions, since a comparison of the
aortic and pulmonic sounds shows the two to be in a normal relation to
each other. The lesions in fact which exist in the case are of no immediate
seriousness, and of this I assured the patient in the most positive manner."

"This case affords an illustration of the importance of discriminating
between functional disorder and the effects of organic disease when there is
evidence of the latter. It illustrates, also, the importance of the heart
sounds and of the size of the heart in determining the gravity of lesions.
The evils which may arise from the lesions (if they ever occur) are remote,
and I felt warranted in assuring the patient that his condition involved no
present danger, and that he might dismiss all thoughts of disease of the
heart. I ordered him to live well and to resume his out-door sports. His
apprehensions were entirely relieved by my assurances, and his expressions
of gratification afforded evidence of what he had suffered mentally from the
idea of an organic disease incapacitating him for the duties of life and
randering him liable to sudden death."

As I have said, this case is a type of a class of cases of not unfrequent
occurrence. The existence of a cardiac murmur was discovered in conse-
quence of an examination with reference to the lungs. Prior to this time
no symptoms of disorder of the heart existed ; the discovery of the murmur
was an unfortunate circumstance for the patient ; the belief that he had
serious disease of heart became fixed in his mind, and doubtless contributed
to the disorder which subsequently occurred. The functional disorder was
slight in comparison with cases which are of daily occurrence ; but the
patient naturally attributed it to organic disease. The affection was in

Flint, Cardiac Murmurs.

fact altogether functional, albeit the existence of an organic murmur ; this
is the practical point which the case is intended to illustrate.

I propose now to consider certain practical points pertaining to the
cardiac murmur separately ; I shall limit my remarks mainly to the mur-
murs produced by the blood-currents, in the left side of the heart, viz., the
aortic direct, the aortic regurgitant, the mitral systolic and the mitral
direct. Exclusive of the pulmonic direct murmur I have but little prac-
tical acquaintance with murmurs emanating from the right side of the
heart.

Aortic direct murmur. — The question whether a murmur be organic or
inorganic has reference generally to a murmur produced by the current of
blood from the left ventricle into the aorta. The aortic regurgitant mur-
mur and a mitral murmur which is truly regurgitant are of necessity
organic; they require lesions involving more or less insufficiency of the
valves. The mitral direct murmur, as will be seen presently, is inorganic
only as a rare exception to the rule. A practical point, then, in certain
cases, is to determine whether an existing aortic direct murmur be organic,
i. e., dependent on lesions, or whether it be inorganic, i. e., dependent on a
blood-change. This point cannot always be positively settled, but when
such is the case it is practically not very important that it should be settled ;
in other words, when a murmur exists concerning which we are at a loss
to decide whether it be organic or inorganic, if it be the former, the lesion
giving rise to it must be trivial, since under these circumstances the heart
sounds will be found to be normal and the heart not enlarged. If in con-
nection with an aortic direct murmur we find the aortic second sound
impaired and the heart enlarged, we are warranted in considering the
murmur organic. But a slight rippling of the current by roughening
from an atheromatous or calcareous deposit which occasions no obstruction,
and no valvular insufficiency, may yield a murmur. How are we to dis-
tinguish this from an inorganic murmur ? The absence of the anaemic
state, of other cardiac murmurs, of arterial murmurs, of the venous hum,
and the persistency and uniformity of the murmur are the circumstances
which render it probable that it is organic ; while the existence of anaemia,
of other cardiac murmurs, of arterial murmurs and the venous hum, together
with intermittency and variableness of the murmur, render it probable that
it is inorganic.

In my work on diseases of the heart, 1859, I have stated roughness of
the murmur to be one of the circumstances showing it to be organic. I
then believed that an inorganic murmur was never rough. The able reviewer
of my work in the Dublin Quarterly says, with regard to this point, "We
are unable to give unqualified assent to the statement that an inorganic
murmur is uniformly soft." The criticism of the reviewer is just; I was
mistaken in the statement as the following case will show: —

1862.]

Flint, Cardiac Murmurs.

I visited in May, 1860, a female patient who presented a loud rasping
murmur which had led to the suspicion of aneurism. The patient was
exceedingly anaemic ; there was total loss of appetite with vomiting and
diarrhoea. The anemia could not be accounted for; it belonged in the
category of cases described by Addison as cases of idiopathic ansemia. I
found a rough rasping murmur at the base of the heart on the right of the
sternum, and a similar murmur was heard over the subclavian and carotid.
On examination after death, in this case, the heart was perfectly normal,
the aortic orifice, the aorta, subclavians, and carotids were free from any
morbid change, and the lungs were healthy. The murmur was evidently
due to a blood change.

The discrimination of an aortic direct from a pulmonic direct murmur
is a point of interest. If the normal situation of the aortic and pulmonic
artery in relation to the walls of the chest be preserved, an aortic direct
murmur has its maximum of intensity and may be limited to the point
where the aorta is nearest the surface, viz., the second intercostal space on
the right side close to the sternum. But the normal relation of the vessels
to the thoracic walls is not infrequently changed when the heart becomes
enlarged, or as a consequence of past or present pulmonary disease, and
hence this murmur may be loudest or limited to the base on the left side
of the sternum. The situation of the murmur or of its maximum, there-
fore, is not always reliable in the discrimination. A pulmonic direct
murmur has its maximum or is limited to the second or third intercostal
spaces on the left side close to the sternum, the artery being at these points
nearest the surface, but, as just stated, an aortic direct murmur may be
found to be loudest in this situation. If the heart be not enlarged or
displaced by pressure from below the diaphragm, the chest not depressed,
and the lungs are free from disease, the fact that a murmur has its maxi-
mum at or is limited to the right side of the sternum, is evidence of its
being aortic rather than pulmonic, and per contra, the fact of a murmur
having its maximum at or being limited to the left side of the sternum, is
evidence of its being pulmonic rather than aortic. But the propagation
of the murmur into the carotid is the most important circumstance in this
discrimination. An aortic direct murmur, unless it be quite weak, is
generally propagated into the carotid. A pulmonic direct murmur of
course cannot be. Here attention to the pitch and quality of sound is
called into requisition. It is to be determined that a murmur heard
over the carotid is propagated from the aorta not produced within the
carotid. How is this to be determined ? Yery easily in most cases, by a
simple comparison of the murmur as heard over the carotid and at the
aortic orifice. If the murmur in the neck be a propagated murmur it will
differ from that at the base of the heart chiefly as regards intensity ; the
pitch and quality will not be materially changed. If it be rough or soft at
the base of the heart, it will be the same in the neck ; if the pitch be high
or low at the base of the heart, it will be the same in the neck. On the

Flint, Cardiac Murraurs.

[July

other hand, a murmur produced within the carotid, will be likely, in the
great majority of cases to differ in quality and pitch from a coexisting
murmur at the aortic orifice.

In accordance with what has been stated with reference to the limitations
of the significance of organic murmurs in general, an aortic direct murmur,
when undoubtedly organic, alone affords little or no information respecting
the nature and extent of the lesions which give rise to it. A comparison
of the aortic with the pulmonic second sound of the heart enables us fre-
quently to form an opinion as regards the amount of damage which the
aortic valve may have sustained. The aortic second sound, in health, as
heard in the right second intercostal space near the sternum, is more intense,
and has a more marked valvular quality, than the pulmonic second sound
as heard in a corresponding situation on the left side. Now, it is often
easy to determine whether the intensity of the aortic second sound is
diminished and its valvular quality impaired ; and in proportion as this
sound is abnormally altered in these respects, we may infer that the aortic
valve is damaged. It is hardly necessary to say that, in order for this
comparison to warrant the inference just stated, pulmonary disease must
be excluded. A tuberculous deposit, for example, on the left side, may, by
conduction, render the pulmonic apparently more intense than the aortic
sound, the latter retaining its normal intensity ; the same will occur from
shrinking of the upper lobe of the left lung so as to bring the pulmonic
artery into contact with the thoracic walls. Under the latter circumstances
the pulsation of the pulmonic artery may sometimes be distinctly felt in
the second left intercostal space near the sternum. I have met with two
cases during the past winter in which the pulsation of the pulmonic
artery was so strong as to suggest the idea of aneurism; in both cases the
patients were affected with tuberculous disease of the left lung. Alteration
of the normal relation of the aorta and pulmonic artery due to enlargement
of the heart, or to any of the causes already mentioned, will of course
preclude a comparison of the two sounds.

With reference to the value of a comparison of the aortic and pulmonic
second sound in estimating the amount of aortic lesions, the able reviewer
in the Dublin Quarterly, to whom I have already referred, and for whose
valuable criticisms I beg to avail myself of this opportunity of expressing
my sincere thanks, remarks as follows:- —

" It is observed, to our great wonder, that if the aortic second sound retain
its normal intensity and purity, it shows that the aortic valve is competent to
fulfil its function, a fact which warrants the exclusion of lesions affecting it
sn.fficienth/ to give rise to ohstruction." He adds, " Surely Dr. Flint must have
become clinically cognizant of the fact that there is not unfrequently serious
contraction of the aortic orifice producing marked obstruction and hypertrophy
of the left ventricle, the aortic second sound remaining intact."

Tills criticism is not altogether just. I state that the normal intensity and
purity of the aortic second sound warrant the exclusion of lesions affecting

1862.]

Flint, Cardiac Murmurs.

it, i. e., the vake, sufficiently to give rise to obstruction. I do not say
that contraction of the aortic orifice may not occur without involving the
aortic valve, and, in such a case, the aortic second sound may remain intact.
In fact, I imply this when I proceed to say, "In a large proportion of the
cases of obstructive lesions of the aortic orifice, the valve is involved
sufficiently to compromise, to a greater or less extent, its function and
impair the intensity of the aortic second sound." This language is equiva-
lent to admitting that there is a small proportion of cases of obstructive
lesions of the aortic orifice, in which the valve is not involved sufficiently
to compromise its function and impair the intensity of the aortic second
sound. These exceptional cases are extremely rare. Surely the able
reviewer will admit that, in the great majority of cases, the valve is involved
so as to impair its function to a greater or less extent.

I have lately been interested in a nice point of observation connected
with the murmur under consideration, viz., the concurrence of two aortic
direct murmurs, one produced at the aortic orifice and another within the
aorta just above the orifice. One of the murmurs may be organic and the
other inorganic, or both murmurs may be organic. At the present moment
I have under observation three cases of endocarditis with rheumatism, each
presenting a high pitched basic murmur when the stethoscope is placed over
the sternum and a little to the right of the median line, the murmur limited
to a circumscribed space, and just above this point, in the right second
intercostal space, is another murmur difi'ering from the former notably in
pitch, being quite low. In one of these cases there is still another murmur
in the pulmonic artery. The high pitched murmur just below the second
intercostal space, as I infer from the situation to which it is limited, is a
murmur produced at the aortic orifice ; and the low pitched murmur just
above, as I infer, also, from the situation to which it is limited, is an aortic
murmur produced within the artery above the aortic orifice. I infer that
there are two murmurs from the notable difference in pitch, it being by no
means probable that a single sound would be so much altered within the
area in which the two murmurs are heard, this area not being larger than
a half dollar. That an aortic murmur is sometimes produced at the orifice
and sometimes within the artery above the orifice, in different cases, is cer-
tain, but I am not aware that the production of a murmur in each situation,
at the same time, in the same case, and the discrimination of the two by
means of the character of the sound, have been pointed out.

Aortic regurgitant murmur. — This murmur need never, as a matter of
course, be confounded with the systolic murmurs, viz., the aortic direct, and
mitral regurgitant, the latter occurring with the first, and the former with
the second sound of the heart. In general, too, there is no difficulty in
distinguishing the aortic regurgitant, from the mitral direct murmur. The
former occurs with and follows the second sound, the latter precedes the

Flint, Cardiac Murmurs.

[July

first sound.. The one is diastolic, . the other is pre-systolic. This is a
distinction, nice, it is true, but easily appreciable in practice, to which I
shall recur under the heading of the mitral direct murmur.

The situation of the murmur is also distinctive. It is best heard at,
and below the base of the heart. Usually it is best heard below the base
to the left of the median line on a level with the third or fourth ribs. This
is doubted by the reviewer in the Dublin Quarterly, to whom I have
referred, but as the statement is based on a pretty large number of recorded
observations, I must consider it as correct. It is not uncommon to hear
this murmur distinctly, and even loudly, over the apex ; it may be diffused
over the whole prsecordia and even propagated beyond this region.

An aortic murmur with the second sound of the heart, propagated below
the base of the heart, necessarily implies regurgitation, in other words
there must be insufficiency of the aortic valvular segments. But it is
always to be borne in mind that no inference can be drawn from the inten-
sity or character of the murmur, respecting the amount of insufficiency
and consequent regurgitation. An extremely small regurgitant stream
may give rise to a loud murmur, while a feeble murmur may accompany a
large regurgitant current, as the rippling brook is noisy while the deep
broad river flows silently. In a case recently under observation, there
existed a loud aortic regurgitant murmur, and on examination after death
the aortic segments were so slightly impaired that, on cursory inspection,
they might have been considered as normal. Weakening or extinction of
the aortic second sound of the heart are points of importance as showing
frequently the extent to which the function of the aortic valve is impaired.
Comparison with the pulmonic sound enables us to judge whether the aortic
sound be impaired, provided the pulmonic sound be not abnormally intensi-
fied as a result of coexisting mitral lesions. It is important to recollect
that when aortic and mitral lesions coexist, the intensity of the pulmonic
sound cannot be taken as a criterion for judging whether the aortic sound
be, or be not weakened. This remark is equally applicable to the com-
parison in cases in which an aortic direct murmur is present. It is needless
to say that in comparing the aortic and pulmonic sound in connection with
an aortic regurgitant, as with an aortic direct murmur, pulmonary disease
is to be excluded, i. e., solidification or shrinking of the left lung will, as
already stated, render the pulmonic sound relatively more intense than the
aortic, irrespective of, on the one hand, any actual increase of the intensity
of that sound, or, on the other hand, of any weakening of the aortic sound.
It is also to be stated here, as heretofore, that an alteration of the situation
of the aorta and pulmonary artery as regards the thoracic walls, due to
enlargement of the heart, or other causes, will preclude a comparison of
the two sounds with reference either to intensification of the pulmonic, or
weakening of the aortic sound.

1862.]

Flint, Cardiac Murmurs.

Mitral systolic murmur. — I use the phrase mitral systolic, instead of
that more commonly used, viz., mitral regurgitant murmur, as applied to any
murmur produced at the mitral orifice and accompanying the first sound of
the heart. If the latter term be applied to any systolic murmur emanating
from the mitral orifice, we fall into the solecism of calling a murmur regur-
gitant in cases in which there is no regurgitation. A mitral murmur may
be produced by mere roughness of the valvular curtains when there is no
insufiiciency of the valve. In this case the murmur cannot be correctly
said to be regurgitant. A mitral systolic murmur, thus, may or may not
be a regurgitant murmur, and, to express this important distinction, we
may say that a mitral systolic murmur exists with or without regurgitation.
The question at once arises, how are we to determine whether a mitral
systolic murmur be regurgitant or non-regurgitant ? This point claims
consideration.

A mitral systolic murmur, as is well known, generally has its maximum
of intensity at, and the murmuring may be limited to, the situation of the
apex-beat, or to the point where the intensity of the first sound of the
heart is greatest. The murmur may be diffused, in the first place, within
this point over the body of the heart, and, in tlie second place, without the
apex over the left lateral surface of the chest and on the back. I have
been led to believe that when the murmur is diffused over the left lateral
surface and more or less over the back, it always denotes regurgitation, and
that when the murmur is not propagated much without the apex, although
it may be more or less diffused over the body of the heart, it may be produced
within the ventricle and not by a regurgitant current. In the latter case
I have distinguished the murmur as an intra-ventricular murmur, and not
considered it as affording any evidence of insuflQciency of the mitral valve.
It is this intra-ventricular, or mitral systolic non-regurgitant murmur,
which generally exists in rheumatic endocarditis. The importance of the
point involved is obvious, for a murmur emanating from the mitral orifice
without valvular insufficiency or regurgitation, denotes lesions of little
immediate consequence, and they may be innocuous, not only for the present
but for the future.

The practical rule just stated, I believe, generally holds good ; but there
may be exceptions. The following is perhaps an exceptional instance : a
case was recently under my observation in Bellevue Hospital, in which acute
rheumatism was complicated with endocarditis, pericarditis, and pleurisy,
with considerable effusion, affecting the left side. This patient presented,
on admission, a loud pericardial friction sound diffused over the whole
prsecordia, and a loud mitral systolic murmur. The latter had its maxi-
mum of intensity at the apex, but was diffused over the left lateral surface
of the chest and heard on the back. After the lapse of about a week the
friction sound disappeared ; but before the disappearance of the friction
sound, the endocardial murmur had gradually diminished and disappeared.

Flint, Cardiac Murmurs.

[July

The pleuritic efifusion also disappeared, and evidence was afforded in this
case of pericardial adhesions by the immobility of the apex-beat when the
body of the patient was placed in different positions. The disappearance
of an endocardial murmur developed by rheumatic endocarditis, so far as
my observation goes, is rare, although I have met with other examples.
I suppose that endocarditis does not involve actual regurgitation save as a
remote consequence of lesions to which the endocarditis may give rise. 1
may be mistaken in this supposition, but, assuming that I am not, here
was an instance in which an intra-ventricular or non-regurgitant mitral
systolic murmur was propagated entirely around the chest.

With reference to determining the existence of either regurgitation or
obstruction, or both, resulting from mitral lesions, a comparison of the
aortic and pulmonic second sound, forms a beautiful and useful application
of auscultation. Obstructive and regurgitant lesions, situated at the mitral
orifice, involving an obstacle to the free passage of blood through the pul-
monary circuit, give rise, as is well known, to hypertrophy of the right
ventricle. In this way they lead to intensification of the pulmonic second
sound of the heart. This effect is due, in part, to the augmented power of
the contractions of the right ventricle, and, in part, to the resistance to
the passage of blood through the lungs, both continuing to increase the
dilatation of the pulmonary artery by the pulmonic direct current, and the
consequent recoil of the arterial coats by which the pulmonic valvular
segments are expanded, and the pulmonic second sound produced. But
the morbid disparity between the aortic and pulmonic second sound is due,
not alone to the intensification of the latter in the manner just stated.
The aortic second sound is weakened in proportion to the amount of blood
which fails to pass into the aorta with the ventricular systole, in conse-
quence of the mitral obstruction or regurgitation. It is obvious that the
aortic direct current will be lessened by the amount of blood which, in con-
sequence of valvular insufficiency, flows backward into the left auricle after
the ventricle contracts, and by the amount of difficulty which exists in the
free passage of blood from the auricle into the ventricle in consequence of
a contracted orifice. It is also obvious that, other things being equal, the
intensity of the aortic second sound will be greater or less according to the
quantity of blood propelled into the aorta by the ventricular systole. Thus
it is clear how mitral obstruction and regurgitation lead to weakening of
the aortic sound, as well as to intensification of the pulmonic sound, and
both effects are abundantly attested by clinical observation.

The degree of weakening of the aortic and of intensification of the pul-
monic sound will be proportionate to the amount of mitral regurgitation
or obstruction, or both. We have then, in this application of ausculta-
tion, a means of obtaining information respecting the extent or gravity of
mitral lesions. And, in a negative point of view, this application is im-
portant, viz., as a means of determining that lesions which give rise to a

1862.]

Flint, Cavdiac Murmurs.

murmur are not serious ; in other words, of determining that they do not
involve much, if any, obstruction or regurgitation. As enabling us to
exclude obstructive or regurgitant lesions in certain of the cases in which
mitral murmurs exist, a comparison of the aortic and pulmonic sound is
of great practical value. But the circumstances which may stand in the
way of this application of auscultation are to be borne in mind. The two
sounds cannot be compared with reference to mitral, more than with refer-
ence to aortic lesions, if there be coexisting pulmonary disease, nor when-
ever the normal relation of the aorta and pulmonary artery to the thoracic
walls is altered by either past or present disease of lungs, by deformity of
the chest, or any other cause. It is also to be recollected that mere enlarge-
ment of the heart may disturb the normal relation of these vessels to the
walls of the chest. This application, moreover, cannot be made when
mitral and aortic lesions coexist. Under the latter circumstances it is, of
course, difficult or impossible to determine how far an existing disparity
between the aortic and pulmonic sound is due to the aortic, and how far to
the mitral lesions.

Another important point pertaining to a mitral systolic murmur is, its
occurrence without any appreciable lesions. A truly mitral regurgitant
murmur doubtless always involves lesions of some kind, for it is hardly
probable that the papillary muscles, as has been supposed, may become
spasmodically affected and thus give rise to insufficiency or regurgitation
as a temporary functional disorder. But it is undoubtedly true that a sys-
tolic murmur either limited to, or having its maximum of intensity near
the apex, has been repeatedly observed in cases in which mitral lesions
were not apparent after death. Dr. Bristowe in a paper contained in the
Brit, and For. 3Ied. Chir. Review, for July, 1861, details six cases of this
description. Dr. Barlow, in an article in Guy^s Hospital Reports, vol. v.,
1859, states that a mitral murmur may occur (for what reason he does
not state) in long-continued capillary bronchitis. I have met with some
instances in which a systolic murmur, supposed to be mitral, existed, and
no mitral lesions were found after death.

Case 1.* In the winter of 1859-60, 1 saw a female patient in the Charity
Hospital, New Orleans, in the service of my colleague, Prof. Brickell,
affected with capillary bronchitis. After several days there was improve-
ment as regards the pulmonary symptoms, and then, for the first time, a
s3'stolic cardiac murmur was discovered. The murmur was loudest at the
epigastrium, but heard over the site of the apex, and extended to, but not
above the base of the heart. The patient subsequently died. On exami-
nation after death the lungs were emphysematous ; there were no valvular
lesions, all the valves appearing to be sound. The foramen ovale was
closed. There were no clots. The right ventricle was distended with
liquid blood. The walls of the heart were of normal thickness. The
valves and orifices were not measured, nor was the water test of valvular
sufficiency employed.

^ Private Records, vol. xi. p. 36.

Flint, Cardiac Murmurs.

[Jaly

In recording this case I have commented on the murmur as follows :
"What could have caused the loud systolic murmur? I cannot say unless
it was due to distension of the right ventricle and tricuspid regurgitation."

In support of the supposition that the murmur was tricuspid, not mitral,
it is to be noted that the greatest intensity was at the epigastrium. It
was, however, considered to be a mitral systolic murmur during life.

Case 2.* During the winter of 1860-61, a patient was under my obser-
vation in the Charity Hospital, New Orleans, for four months, affected with
albuminuria and general dropsy. During all this time there was a mitral
systolic murmur heard at the apex and over the body of the heart, and not
propagated without the apex. It was regarded as a mitral systolic, non-
regurgitant or intra-ventricular murmur, and as such pointed out to several
private classes in auscultation. The patient died by asthenia, and was found
to have fatty kidneys and cirrhosis of the liver. On examination of the
heart, post mortem, nothing abnormal was found except some enlargement,
the organ weighing 12 oz., and a little separation of the marginal extremity
of two of the aortic segments. The mitral valve appeared to be perfectly
normal. I expected to find some roughening of the mitral valve but no
insufficiency; there was, how^ever, no atheromatous, calcareous or other
deposit, and the valve seemed to be sufficient. There was no aortic, nor
pulmonic murmur in this case, a fact which excludes the supposition that
the existing murmur was due to the condition of the blood.

Case 3.^ During the winter of 1860-61, a patient was under my obser-
vation in the Charity Hospital, New Orleans, for about six weeks, affected
with chronic bronchitis and emphysema of lungs. He presented habitual
dyspnoea which was at times excessive, persisting lividity and anasarca.
The heart was evidently somewhat enlarged. There was a loud rough
systolic murmur, having its maximum of intensity at the apex propagated
without the apex (the record does not state how far), and over the body
of the heart. On examination after death the volume of the heart was
not much increased, and its weight was 13 oz. The left ventricle was not
dilated and the left auricle was small. The walls of the left ventricle did
not exceed half an inch in thickness, and the appearance of the muscular
tissue was healthy. The mitral valve was perfectly normal. The orifice
was not enlarged, and the valve must have been sufficient. No lesion at
the aortic orifice. The right cavities were much dilated. They were twice
as large as the left cavities. The walls of the right ventricle were much
thickened, the thickness falling but little short of that of the left ventricle.
No lesion of the pulmonic orifice. The tricuspid valve was normal. The
orifice was very large, admitting the extremities of all the fingers. I have
appended to the record of this case the following comment : "Whence thfe
murmur supposed to be a mitral regurgitant? I suspect it was a tricuspid
regurgitant."

Dr. Bristowe, in the article already referred to, discusses several conditions
which have been supposed to give rise to the murmur in cases like those
which have just been given, viz., clots in the ventricular cavity, spasm of
the papillary muscles, and enlargement of the auricular orifice so as to

' Private Records, vol. xi. p. 243.
^ Hospital Records, vol. xv. p. 423.

1862.]

Flint, Cardiac Murmurs.

render the valve insufficient. His own opinion is tliat the murmur is due
to a " disproportion between the size of the ventricular cavity and the length
of the chordas tendinae and musculi papillares." This disproportion he
attributes to dilatation of the cavity of the ventricle. He also accepts to
some extent an explanation offered by Dr. Hare, viz., that the murmur
may be due to a "lateral displacement of the origins of the musculi papil-
lares in consequence of the rounded form which dilatation imparts to the
heart."

These several explanations may each be applicable to certain cases, but
none of them, apparently, to the cases which I have given. Clots in the left
ventricular cavity were not present in either of' the cases ; the murmur con-
tinued too long and too persistently to be due to spasm ; the mitral orifice
was not dilated, and the enlargement of the heart was not sufficient to occa-
sion a notable disproportion between the length of the tendinous cords and
papillary muscles, and the ventricular cavity. I am disposed to think that in
each of the three cases the murmur was erroneously considered to be mitral ;
that it was a tricuspid regurgitant murmur. As I have already said, I have
but little practical knowledge of tricuspid murmurs. I have met with two
instances in which murmur was connected with well-marked tricuspid lesions
as verified by examination after death. In both these cases the murmur
was heard over the body of the heart, within the superficial cardiac region.
I suspect that a tricuspid regurgitant murmur is not so rare as is generally
supposed, and that not very infrequently it is <?onsidered to be mitral. This
opinion is expressed by Dr. Gairdner in an interesting article on cardiac
murmurs in the Edinburgh Med. Monthly, Nov. 1861. According to this
able clinical observer, a tricuspid systolic murmur is heard over the right
ventricle where it is uncovered of lung, being but slightly audible above
the third rib ; and, if the heart be much enlarged, it may be heard louder
towards the xiphoid cartilage. A collection of clinical facts respecting the
frequency of tricuspid murmurs, the physical conditions giving rise to them,
and the means of discriminating them from mitral murmurs, is an important
desideratum.

Mitral direct murmur. — This murmur is not recognized by many aus-
cultators, and its existence is denied by some. It is generally confounded
with a mitral systolic murmur. For many years after I had begun to devote
special attention to cardiac affections, I committed this mistake, and I was
sometimes puzzled to account for a supposed mitral systolic murmur rough
at its beginning and soft at its ending. In my records of some cases before
I had learned to separate the mitral direct from a mitral regurgitant, I
have described the latter as presenting the variation just stated, the fact
being that the two murmurs were present, the one rough and the other
soft. It is only within the last few years that I have discriminated these
two murmurs, but during this time my field of clinical observation has

Flint, Cardiac Murmurs.

[July

been so extensive that I have had abundant opportunities to make the dis-
crimination. With regard to the frequency of the mitral direct murmur,
it is by no means so rare as is generally supposed, and as I had thought
some yeairs ago. At one time during the past winter, in Bellevue Hospital,
I knew of six examples of it, and several also at the Blackwell's Island
Hospital. When the auscultator has learned to distinguish it, he will not
be long in finding it if he be in the way of seeing a moderate number of
cases of disease of the heart. From what has now been said, it is obvious
that an important point pertaining to this murmur is, its discrimination
from other murmurs. This point will first claim consideration.

In order to comprehend this murmur, it is essential to understand clearly
when the mitral direct current of blood takes place. The opportunity of
observing the movements of the heart exposed to view in a living animal,
conduces greatly to a clear understanding of this point. The mitral direct
current is produced by the contraction of the auricles ; now, when do the
auricles contract ? When the movements of the heart are observed, it is
seen that the contraction of the auricles immediately precedes the contrac-
tion of the ventricles. So close is the connection between the contraction
of the auricles and the contraction of the ventricles, that the former appears
to merge into the latter; there is no appreciable interval between the two, but
the successive movements, although distinct, appear to be continuous. More-
over, it is evident to the eye, and to the touch, that the contractions of the
auricles are not so feeble as some seem to suppose. The mitral direct cur-
rent of blood, therefore, occurs just before the ventricular systole ; it con-
tinues up to the ventricular systole, and must, of course, instantly cease
when the ventricles contract. The contraction of the ventricles causing
the first sound of the heart, it follows that the mitral direct current caused
by the auricular contractions must take place just before the first sound ;
that it must continue to the first sound, and that it cannot continue an
instant after the first sound.

The mitral direct murmur is produced by the mitral direct current of
blood forced by the auricular contractions through a contracted or rough-
ened mitral orifice. Hence, the facts just stated with regard to the current,
apply to the murmur. The murmur occurs just before the ventricular sys-
tole or the first sound of the heart ; it continues up to the occurrence of
the first sound, and instantly ceases when the first sound is heard. It is
not strictly correct to call this a diastolic murmur ; it does not accompany
the second or diastolic sound of the heart. The aortic regurgitant is the
only true diastolic murmur. The mitral direct is a pre-systolic murmur ;
this name expresses its proper relation to the heart sounds, and it is the
only murmur which does occur in that particular relation. The time of its
occurrence as just explained, and as expressed by the term pre-systolic, is
sufficient for its easy recognition when once it is fully comprehended.
Although, when this murmur is fully comprehended, and has been repeatedly

1862.]

Flint, Cardiac Murmurs.

verified, it is more readily recognized than either of the other murmurs,
there is often at first considerable difficulty in determining its existence.
Let me endeavour to point out the way in which it may be ascertained. I
have already said that by those who overlook this murmur it is generally
confounded with the mitral systolic or regurgitant murmur. This is in
consequence of its close connection with the first sound, and because it
is heard at and near the apex of the heart. Now it is evident that a mitral
systolic murmur cannot commence before the ventricular systole. It is
equally evident that the ventricular systole and the first sound of the heart
are synchronous. It is, therefore, an absurdity to suppose that a mitral
systolic or regurgitant murmur can be pre-systolic in the time of its occur-
rence. This murmur must necessarily accompany and follow the first sound
of the heart, as clinical observation has established. We have, then, only
to determine that a murmur is pre-systolic, and that it does not accompany
the second sound of the heart (z. e., there is an appreciable interval of time
between the second sound and the murmur), to recognize it as a mitral
direct murmur. Generally it is sufficiently easy, after a little practice, to
perceive that the murmur precedes the sound, but, if there be difficulty or
doubt, there is a ready mode of rendering it apparent ; this Is by placing
the finger on the carotid pulse. The carotid pulse is synchronous with the
first sound of the heart, or, at least, so nearly synchronous, that there is
no appreciable interval of time between them. Placing, then, the finger
on the carotid and listening to the murmur at the apex, the murmur is
found to occur before the arterial impulse and to cease instantly when the
latter is felt.

The mitral direct murmur is to be discriminated from an aortic regurgi-
tant murmur. These two murmurs may be confounded at first, but after
a little practice the discrimination is easy. The aortic regurgitant murmur
accompanies and follows the second sound of the heart. The mitral direct
commences after the second sound. Generally there is a distinctly appre-
ciable interval of time between the second sound and the commencement
of the murmur. The aortic regurgitant murmur may be prolonged nearly
or quite through the long pause up to the first sound ; but the intensity of
the murmur diminishes with the prolongation, the murmur being insensibly
lost before or when the first sound occurs. The mitral direct murmur, on
the contrary, always continues up to the first sound, and instead of losing
any of its intensity, it becomes more intense, and appears to be abruptly
arrested, in its greatest intensity, when the first sound occurs. This is a
striking characteristic. The difference in the situation in which two mur-
murs respectively are heard with their maximum of intensity, is another
point in the discrimination. The aortic regurgitant murmur is generally -
heard at the base of the heart, and is heard loudest a little below the base
near the left margin of the sternum on a level with the third intercostal
space. The mitral direct murmur is heard loudest at or a little within the
No. LXXXYII July 1862. 4

Flint, Cardiac Murmurs.

apex ; is generally confined within a circumscribed space, not propagated
much without the apex and rarely to the base of the heart.

The quality of the mitral direct murmur is, in many cases, characteristic.
In my work on diseases of the heart I have said that this murmur is gene-
rally soft. My experience since that work was written has shown me that
this statement is incorrect. The murmur is oftener rough than soft. The
roughness is often peculiar. It is a blubbering sound, resembling that pro-
duced by throwing the lips or the tongue into vibration with the breath in
expiration. I suppose that the murmur is caused, in these cases, by the
vibration of the mitral curtains, and that the vibration of the lips or tongue
by the breath represents the mechanism of the murmur as well as imitates
the character of the sound. At one time I supposed this blubbering mur-
mur denoted a particular lesion, viz., adhesion of the mitral curtains at
their sides, forming that species of mitral contraction known as the button-
hole slit; but I have found this variety of murmur to occur without that
lesion, and, in fact, as will be seen presently, when no mitral lesion whatever
exists.

A mitral direct murmur may, or may not, be associated with a mitral
systolic murmur. Without having analyzed the numerous examples which
I have recorded during the last few years, I should say that, while the
mitral systolic murmur is much more frequent in its occurrence than the
mitral direct, the former, indeed, being the most common of all the mur-
murs, the mitral direct is observed quite as often without, as with the
mitral systolic. But the two frequently coexist, and then the demonstra-
tion of the existence of the mitral direct murmur may be made more striking
than when it exists alone, provided, as is usually the case, this murmur be
rough and the mitral systolic murmur be soft. Listening at or near the
apex in a case presenting a blubbering mitral direct and a soft mitral sys-
tolic murmur, the former, of course, precedes the latter, and between the
two occurs the first sound of the heart, the apex-beat and the carotid pulse.
The first sound, the apex beat or the carotid pulse will be found to mark
the abrupt ending of the mitral direct, and the beginning of the mitral
systolic murmur. The different relations of the two murmurs to the first
sound are distinctly perceived in such a case if the observer be prepared to
perceive them by a clear comprehension of the subject. And when once
the discrimination between the two murmurs has been fairly made, it be-
comes sufficiently easy; indeed, the mitral direct murmur is then more
readily recognized than either of the other murmurs.

The existence of a mitral direct murmur has been theoretically denied
on the ground that the auricular contractions are too weak to propel the
current of blood with sufficient force to give rise to a sound. It is un-
doubtedly true that, other things being equal, the intensity of a murmuir
is proportionate to the force of the current, and clinical observation shows
that sometimes a murmur is not appreciable when the heart is acting feebly,

1862.]

Flint, Cardiac Murmurs.

but becomes distinct when the power of the heart's action is from any
cause increased. But murmurs do by no means always require for the
production a powerful action of the heart ; on the contrary, loud murmurs
are often found when the heart is acting very feebly. For example, I have
reported a case in which an aortic direct and an aortic regurgitant murmur
were well marked in a patient an hour before death, the patient dying from
paralysis of the heart due to distension of the left ventricle. Yenous mur-
murs in the neck are often notably loud when, assuredly, the force of the
current of blood in these veins is vastly less than the current from the
auricles to the ventricles. The feebleness of the current in this instance is
shown by the slight pressure requisite to interrupt it and arrest the murmur.
It requires but little force of the expiratory current of air to throw the
lips into vibration so as to produce a loud sound. Moreover, one has only
to see and feel the contractions of the auricle, when the heart is exposed
in a living animal (the heart's action being much weakened under these
circumstances) to be convinced that the power of these contractions is not
so small as some seem to imagine ; the blood is driven into the ventricles
with considerable force. It is hardly necessary to say, however, that d
priori reasoning with regard to the existence or non-existence of physical
signs is not admissible. Their existence is a matter to be determined by
direct observation. Clinical observation shows that a murmur does occur
at the precise time when the mitral direct current takes place as shown by
observation of the movements of the heart exposed to view in a living
animal. And clinical observation shows that this murmur is not always
feeble, but, on the contrary, is not infrequently notably loud.

So much for the reality of the mitral direct murmur and the means of
discriminating it from other murmurs. It remains to consider another
important practical point, viz., the pathological import of this murmur.
As already stated, it is developed in connection with a contracted mitral
orifice, and, so far as my experience goes, especially in connection with con-
traction caused by adherence of the mitral curtains, forming the buttonhole
slit; the murmur, then, being due, not to the passage of blood over a rough-
ened surface, but to the vibration of the curtains. And the sound, as thus
produced, is peculiar, resembling the sound which may be produced, in an
analogous manner, by causing the lips to vibrate with an expiratory pulf.
The murmur, however, may be produced by the flowing of the current of
blood over a roughened surface, without contraction of the aperture. This
is undoubtedly rare. As a rule, the force of the mitral direct current is
not sufficient' to develop a murmur unless there be mitral contraction. Is
this murmur ever produced without any mitral lesions ? One would d pri-
ori suppose the answer to this question to be in the negative. Clinical
observation, however, shows that the question is to be answered in the
affirmative. I have met with two cases in which a well-marked mitral direct
murmur existed, and after death in one of the cases no mitral lesions were

Flint, Cardiac Murmurs.

[July

found; in tlie other case the lesion was insignificant. I will proceed to
give an account of these cases, and then endeavor to explain the occurrence
of the murmur.

Case 1.^ In May, 1860, I examined a patient, aged 56, who had had
repeated attacks of palpitation, sense of suffocation, with expectoration of
bloody mucus and a feeling of impending dissolution, but without pain, the
paroxysms resembling angina, excepting the absence of pain. In the inter-
vals between these attacks he was free from palpitation, did not suffer from
want of breath on active exercise, and considered himself in good health.
He had never had rheumatism. On examination of the chest, the heart
w^as found to be enlarged, the enlargement being evidently by hypertrophy.
At the apex was a pre-systolic blubbering murmur, which I then supposed to
be characteristic of the button -hole contraction of the mitral orifice. At
the base of the heart was an aortic regurgitant murmur, which was diffused
over nearly the whole prsecordia. There was no systolic murmur at the
base or apex. Three days after this examination the patient was attacked
with another paroxysm, and died in a few moments after the attack, sitting
in his chair. The heart was enlarged, weighing 16 J oz., the walls of the
left ventricle measuring |ths of an inch. The aorta was atheromatous, and
dilated so as to render the valvular segments evidently insufficient. The
mitral valve presented nothing abnormal, save a few small vegetations at
the base of the curtains, as seen from the auricular aspect of the orifice.

In this case it is assumed that the mitral direct murmur, which was loud
and of the blubbering character, was not due to the minute vegetations
which were found after death. There was no mitral contraction. The
mitral valve was unimpaired, so that the murmur could not have been due
-to mitral regurgitation.

Case 2.^ In February, 1861, I was requested to determine the murmur
in a case at the Charity Hospital, New Orleans. I found an aortic direct
and an aortic regurgitant murmur, both murmurs being well marked. There
was also a distinct pre-systolic murmur within the apex, having the blubber-
ing character. On examination after death, the aorta was dilated and
roughened with atheroma and calcareous deposit. The aortic segments
were contracted, and evidently insufficient. The mitral curtains presented
no lesions; the mitral orifice was neither contracted nor dilated, and the
valve was evidently sufficient. The heart was considerably enlarged, weigh-
ing 17|- oz., and the walls of the left ventricle were an inch in thickness.

In the second, as in the first of the foregoing cases, it is evident that a
mitral systolic murmur was not mistaken for a mitral direct murmur, for in
both cases, the conditions for a mitral systolic murmur were not present.
In both cases the mitral direct murmur was loud and had that character of
sound which I suppose to be due to vibration of the mitral curtains. In
both cases, it will be observed, an aortic regurgitant murmur existed, and
aortic insufficiency was found to exist post mortem. How is the occurrence
of the mitral direct murmur in these cases to be explained? I shall give
an explanation which is to my mind satisfactory.

' Private Records, vol. x. p. 713.

2 Ibid., vol. xi. p. 241.

1862.]

Flint, Cardiac Murmurs.

The explanation involves a point connected with the physiological action
of the auricular valves. Experiments show that when the ventricles are
filled with a liquid, the valvular curtains are floated away from the ventri-
cular sides, approximating to each other and tending to closure of the
auricular orifice. In fact, as first shown by Drs. Baumgarten and Hamer-
nik, of Germany, a forcible injection of liquid into the left ventricle through
the auricular opening will cause a complete closure of this opening by the
coaptation of the mitral curtains, so that these authors contend that the
natural closure of the auricular orifices is effected, not by the contraction of
the ventricles, but by the forcible current of blood propelled into the ventri-
cles by the auricles. However this may be, that the mitral curtains are
floated out and brought into apposition to each other by simply distending
the ventricular cavity with liquid, is a fact sufficiently established and easily
verified. ISTow in cases of considerable aortic insufficiency, the left ventricle
is rapidly filled with blood flowing back from the aorta as well as from the
auricle, before the auricular contraction takes place. The distension of the
ventricle is such that the mitral curtains are brought into coaptation, and
when the auricular contraction takes place the mitral direct current passing
between the curtains throws them into vibration and gives rise to the cha-
racteristic blubbering murmur. The physical condition is in effect analogous
to contraction of the mitral orifice from an adhesion of the curtains at their
sides, the latter condition, as clinical observation abundantly proves, giving
rise to a mitral direct murmur of a similar character.

A mitral direct murmur, then, may exist without mitral contraction and
without any mitral lesions, provided there be aortic lesions involving con-
siderable aortic regurgitation. This murmur by no means accompanies
aortic regurgitant lesions as a rule; we meet with an aortic regurgitant
murmur frequently when not accompanied by the mitral direct murmur.
The circumstances which may be required to develop, functionally, the latter
murmur, in addition to the amount of aortic regurgitation, remain to be
ascertained. Probably enlargement of the left ventricle is one condition.
The practical conclusion to be drawn from the two cases which have been
given is, that a mitral direct murmur in a case presenting an aortic regur-
gitant murmur and cardiac enlargement, is not positive proof of the exist-
ence of mitral contraction or of any mitral lesions. The coexistence of a
murmur denoting mitral regurgitation, in such a case, should be considered
as rendering it probable that the mitral direct murmur is due to contraction
or other lesions, and not functional.

Dr. Gairdner, in a recent article already referred to, proposes a change
of name for the mitral direct murmur. He proposes to call it an auricular
systolic murmur. Inasmuch as the murmur is produced by the systole of
the left auricle, this name is significant. And the usual name is open to
this criticism, viz. : it is not produced by the whole of the mitral direct
current, but only that part of the current which is caused by the contraction

Dickson, Smallpox.

[July

or systole of the auricle. From the situation of the auricles as regards the
ventricles, the former being placed above the latter, and the free communi-
cation by means of the auriculo-ventricular openings, the blood must begin
to flow from the auricles into the ventricles the instant the ventricular con-
tractions cease. During the first part of the long pause or interval of
silence, i. e., the period after the second sound and before the subsequent
first sound of the heart, the blood flows from the auricles into the ventricles
simply in obedience to gravitation. It is not ascertained that this part of
the current ever gives rise to a murmur. If it does, the murmur would
follow immediately the second sound, or when an aortic regurgitant murmur
occurs. I have conjectured that such a mitral direct murmur may occur,
and that it is confounded with an aortic regurgitant murmur. This con-
jecture is based on cases in which an apparent aortic regurgitant murmur
existed, and the aortic valves seemed to be nearly or quite sufi&cient on
examination after death. However this may be, the mitral direct current
giving rise to the murmur which has been considered in this article, is not
the current which immediately follows the second sound, and is due to gra-
vitation alone, but it is the current immediately preceding the ventricular
systole, and due to the systole of the auricle. Hence, as it seems to me,
the name proposed by Dr. Gairdner, being more specific and accurate, is to
be preferred to that in common use.

Art. III. — On Smallpox, and the Means of Pr^otection against it. By
S. Henry Dickson, M. D., Professor of the Practice of Medicine in
Jefferson Medical College, Philadelphia,

The exanthemata may fairly claim a high place among the topics of
greatest and most constant interest to the medical practitioner. They
seem to solicit attention by their marked and impressive features ; and
present so many palpable, well-defined, objective phenomena, that we feel
always as if on the point of receiving some clear and instructive develop-
ments from the study of the facts observed in their history and progress.
At first sight their origin appears to be plainly traceable, their diagnosis
distinct and easy, their nature obvious. But a closer examination will soon
convince us that our knowledge of them is by no means so satisfactory as
we had imagined, and that the field is still open for further and more
minute exploration.

Three of the class of diseases to which the name has been attached ex-
hibit in common certain striking characteristics, exclusively their own, and
therefore well deserve to be set apart from all others, and arranged together.
Smallpox, scarlatina, and measles are all of them eruptive affections, py-

1862.]

Dickson, Smallpox.

rectic, contagious, self-limiting, and self-protective. They stand alone as
to the concurrence of these conditions, one or more of which may belong
to certain maladies, but all of them to none beside. Thus, hooping-cough,
with no cutaneous eruption, is pyrectic, contagious, self-protective, and
somewhat vaguely self-limiting. Dengue is irregularly eruptive as to con-
stancy, characteristic appearance, and periods, though contagious and pro-
bably self-protective. Erysipelas is neither self-limiting nor self-protective ;
and the same negatives are true of varicella. It is perhaps worthy of
remark in this connection, that all maladies which attack the human sub-
ject but once, and are in this sense self-protective, have been by various
authorities regarded, and with some ,show of plausibility, as among the
exanthemata. Pertussis is so considered by Watt ; typhus and typhoid by
many pathologists ; Hildebrand ranges yellow fever thus in the catalogue,
and several of our American brethren have confounded it with dengue,
which has vastly better, though still insufficient, claims to that position.

The well-arranged, carefully prepared, and valuable " Report on Meteor-
ology and Epidemics for 1861," read by Dr. Jewell before the College of
Physicians of Philadelphia on the 5th of February, 1862, and published in
the last (April) number of this Journal, contains some appalling statements
in reference to the three pestilential affections there exclusively denominated
exanthems. We learn from it that in the city of Philadelphia, containing
568,034 inhabitants, there died within twelve months from smallpox 158
persons; from scarlatina 1190 ; and from measles (of which it should be
recollected that the fatal results are in great proportion indirect and masked
under other names) 14. With most commendable industry, and with an
intelligent zeal which entitles him to the thanks and highest respect of our
profession. Dr. Jewell has collated, tabularly and otherwise, a large mass
of useful facts and observations, in addition to the mere statistics of his
report. Going back to 180T, he places before us a comparative view of
the annual mortality of the most loathsome and destructive among them.
We find it recorded of smallpox, which has figured largely in the bills of
mortality for several years past, that the next highest number of deaths
took place in 1852, 421 ; in 1856, 390 ; in 1824, 325. This terrible pes-
tilence was, last year, about twice as fatal as at any time during the current
century, with the exception of the year 1852, when the difference, 331, was
not far below the greatest amount of mortality in the worst other year of
the century. We cannot avoid being shocked at this retrograde exhibition,
and shrinking from the acknowledgment of professional failure and defeat
which it seems to imply. We are apt to take for granted — nay, I will
maintain it to be positively true— that, fatal as this disease is even now, its
proportional mortality has been vastly reduced. Fewer of those attacked
die of it than formerly by a great difference, and we have occasion to notice
much less deformity and mutilation by it. Allowing, then, for this dimin-
ished violence and destructiveness, we contemplate with horror the im-

Dickson, Smallpox.

[July

mense mass of suffering which must in this community have overwhelmed
the multitudes of miserable sick who passed through its wretched stages
of varying infliction, recovering finally ; many of them, doubtless, through
tortures far worse than death itself. If we carry out our thoughts to the
soldiers of the great armies now in the field, and the camp followers, and
attendants, and refugees of all sorts, upon whom this scourge is widely and
heavily laid, we shall shudder with quivering sympathy, and painfully lament
the woes of our frail and afflicted race. And yet farther ; when we reflect that
all these horrors were preventible, and ought to have been prevented, our
sympathy will be freely mingled with shame and remorse ; shame, that in
the light of advancing civilization, governments and law-makers should
not have accepted, instituted, and enforced the proper means of preserva-
tion from such evil ; and remorse at our remissness as a professional body,
intrusted with the care of the physical well-being of our fellow-men, in
not having urged, with unceasing and irresistible importunity, measures at
once so important and so feasible. Dr. Jewell quotes and adopts the re-
mark of an English writer, " that the absence of an efficient system of
protection should be considered a national disgrace ; almost a national
crime and we must all acquiesce in and feel deeply the truth of the im-
putation.

I have read with much pleasure the observations made by Dr. Nebinger
before the Philadelphia County Medical Society, on the 13th of ^^ovember,
1861, on the subject of this essay, and given to the public in the Fhil.
3Ied. and Surg. Reporter, of March 29, 1862. I have already stated my
accordance in his opinion that smallpox is better treated, and more suc-
cessfully, now than in the days of Sydenham. During a long course of
practice, I have myself lost so small a proportion of my variolous patients,
that I am fully prepared to accept the favourable view he presented of his
own good fortune. The data he then offered will assist us to estimate —
approximately — the number of sick who suffered, but did not die. This is
an essential element to a fair appreciation of the real value of prevention.
I have always considered it a matter of great regret that we have no re-
cord of the extent of actually existing disease; its frequency; its dura-
tion ; its degree ; its calamitous privations and inflictions. Such a register
is a necessary complement to the bare ''bills of mortality," useful and
instructive as these have become in the hands of Dr. Jewell and his colla-
borators.

Dr. Nebinger had seen more than 30 cases : he had among them 5 con-
fluent ; but one death occurred from them all. He ascribed this large
success to his energetic efforts to sustain the strength of his patients dur-
ing the progressive stages of maturation, suppuration, desquamation, and
redintegration of cutis.

In a report prepared by Drs. Bell and Mitchell, of this city, we have a
table of 248 cases given, of which 89 died — in the epidemic of 1823-24.

1862.]

Dickson, Smallpox.

I saw smallpox prevailing extensively in New York during 1848 and
1849. Many of the members of the medical class in the University in
which I then held the chair of the Practice of Physic, were attacked ; of
these, 50 or more in number, only 2 died. Averaging these three state-
ments, each of which is extreme, two of them in good fortune, and one in
the reverse, we have 1 death in about 3 J cases, reaching a total of 2653
sick.

Gregory estimates the average mortality all over the world as 1 in 6.
In Dr. John Davy's Notes and Observations on the Ionian Islands and
Malta, there is an interesting history of "the Variolous Epidemic of
1830-31, in Malta." The deaths were llt2 out of 806Y cases reported ;
" many cases occurred which were not reported ; of the mildest kind, pro-
bably." These proportions would give us about 5000 cases of smallpox
in one year in this favoured city. If we take from the very happy rate of
success announced by Dr. Nebinger, fully two-thirds — and we should re-
member that both Drs. Burns and Remington ''fully agreed with him, and
added their testimony as to the good results of his mode of treatment" — if
we admit, I say, that Dr. N. was singularly fortunate, and subtract two-
thirds as approaching the more general average, making the deaths 1 in 10
of the whole aggregate of cases, we shall find our sick amounting to 1580.
What an accumulation of anguish ! What an infinite sum of wretched-
ness ! Pew of them could have been ill a shorter time than a week, in
greater or less degree ; at least half of them would be in an invalid con-
dition, and in a state of feeble convalescence for two and three weeks, many
even more than this ; and although two-thirds of them were young chil-
dren, yet they would require, each of them, an adult attendant. Putting
the average duration of illness, then, at ten days, 15,800 days of useful
life would be lost to the individuals ; of ordinary labour to the community
— more than two hundred years of privation, suffering, and sorrow !

This calculation would be irrelevant and useless, if we were treating of
an inevitable form of calamity; but I hold the contrary to be positive truth
here. I believe it to be in the power of all civilized and well governed
communities to confine within very narrow limits, or rather to exterminate
the pestilence under discussion. I contend that it is their bounden duty to
set about this purpose at once and without delay, and to press the effort
with energetic constancy. It is hardly requisite, I presume, that I should
explain my meaning in the use of the words ''extermination" and "extir-
pation." I surely have not conceived the idea of physical annihilation of
the virus of smallpox, or the disease variola, ontologically or dynamically
considered. What I intend and aim at is its extinction as an epidemic, as
a pestilence; its obliteration from the bills of mortality. It will be seen
that the course which I am about to propose with this view implies the
constant employment, and of course the preservation of smallpox matter,
as we now keep up and preserve the vaccine. It may happen, which

Dickson, Smallpox.

[July

Heaven grant ! that this dreaded virus may hereafter become difficult to
procure, and a supply will need to be sought out of the bounds of civiliza-
tion and well-ordered governments. Such a supply will always doubtless
be within reach, among the barbarous hordes of Africa, Asia, and South
America.

But if we may trust in familiar observation and repeated tabular state-
ments, we are possessed of means of defence against the spread of this
repulsive malady, and also against its fatal violence, which may be made
available to an extent as yet matter only of reasonable calculation and
hopeful estimate. Very few deaths proportionally or absolutely occur from
inoculated smallpox ; very few from smallpox after vaccination : it will
be seen that I would combine universally and regularly the modifying
and palliative influences of the two, by inoculation superimposed upon
vaccination. In two out of three cases hereafter referred to, the result of
such inoculation was "local affection without any fever or eruption; in
the third, local affection without fever, but with papular eruption on the
seventh day, not advancing to vesicles." It remains to be ascertained
whether such effects as these would comprise the general history on a great
scale ; and whether the influence exerted on the constitution would be as
thoroughly protective as I am disposed to anticipate. Should there be no
disappointment in these respects, surely it is not visionary to hope for as
few deaths from smallpox in the next generation as now from vaccine.

The majority, even of my professional brethren, may perhaps continue
to think that I exaggerate the competency of the means proposed : yet no
one will doubt or deny that much, very much of what is contemplated,
may be done by their vigorous and unremitting application. In order
properly to appreciate, however, the value and probable efficacy of our
means of restriction, prevention, and extirpation, we must carefully con-
sider the modes of origin and propagation of the disease we are to contend
with.

1. D©es variola ever arise spontaneously, or from ordinary contingencies,
or under any known or suggested circumstances of defective or vicious
hygiene ?

2. Does it arise from degradation or intensification of any other known
forms of disease, which may themselves originate spontaneously or acci-
dentally? Or,

3. Does it always require a specific infection, an implantation, or efficient
impression from a previous case fully and characteristically developed?
There are no other imaginable alternatives, I believe ; and it is not easy
to obtain an answer perfectly satisfactory to either of the above questions,
although we may reach a fair practical result.

1. I will not venture to deny the possibility of "spontaneous generation"
of smallpox. It came into existence once, and therefore logically may again
occur, provided the same conditions coincide again to produce it. Nor am

1862.]

Dickson, Smallpox.

I unaware that there are several instances on record, in which the breaking
out of the disease has been totally unaccountable. Nay, I hare myself met
with and published a history of one of the strongest and strangest among
the cases that have been observed. I need not say that such rare facts
ought to be studied with the admission that our knowledge of the entire
range of details must always be incomplete, and that it will be safest and
most reasonable to follow the patent and obvious course of known ana-
logies in forming our opinions. Ordinary pollutions of the atmosphere
produce their known effects ; none have been defined or even conjectured
of a nature causative of variola. It is easy to enumerate and imagine
obscure and extremely varied modes of its infectious communication wher-
ever social and commercial intercourse obtains. "We know the tenacity of
its contagion, and shall treat of its great diversity of vehicles. We have
no account of its outbreak where such conveyance was not demonstrably
possible at least ; and if possible, it at once becomes more probable and
presumable than the vague hypothesis of "spontaneous generation." Be-
sides this, speaking practically, such instances will be amenable to the same
methods of prevention that will affect, as we hope, all the others, and even
in special degree. For there is no alleged example, among all these strange
seizures, of persons protected, either by vaccination or previous attack,
having been the subjects of obscure invasion. These yield only to the more
vehement impressions of obvious and definite exposure.

2. The second inquiry presents some intrinsic difficulties, and is not
readily disposed of. We might at once cut the Gordian knot, and pro-
nounce dogmatically with Copeland and Gregory that "the whole confusion
arises from mistaken diagnosis but I will not think or speak thus lightly
of the observations and opinions of such men as Howitz and Bateman,
and Hennen and Thomson. The very authorities above quoted admit
"that there is a form of smallpox w^hich may be mistaken for varicella;"
Gregory makes indeed a class of "varicelloid cases." The true question is
whether or not they actually run into each other, and are capable of mutual
generation. Of the difficulty of clearly distinguishing them, every prac-
titioner should be cautiously aware. Dr. Davy tells us of the Maltese
epidemic of 1830-31, that "in most instances when the disease occurred
after vaccination, it was mild and short in its course, often resembling
chicken-pox rather than smallpox. Chicken-pox was at the same time
common, ninety-one cases being reported." He regards the diagnosis as
doubtful, and mentions a case occurring three months after the last report
of smallpox, which he "thought to be genuine variola, though mild. It
was among some cases of chicken-pox that it happened." Gregory, dwell-
ing on the capricious mingling of the severe and slight varieties of small-
pox, says, "A confluent case shall give origin to a varioloid, and a mild
distinct, and even a varicelloid case ; and these shall generate in their turn
malignancy and confluence."

Dickson, Smallpox.

[July

Tlie spontaneity, that is, the independence of any specific sources of pro-
duction of varicella is universally taken for granted. It has never been
proved, nor, on the other hand, so far as I know, questioned. Yet it has
clearly, a very relevant and important bearing upon our main subject.
Enough has been said to show the danger of error here. ^Nevertheless,
and in spite of all these warnings, fatal mistakes continue to be made by
experienced physicians. On three occasions I have known smallpox to
spread from infection communicated by cases pronounced to be varicella ;
the first and introducing instances being slight and of mild character, fol-
lowed by development of marked cases of violence and malignity. I have
now before me a melancholy ''appeal to the public" of a city into which
the writer had been the unhappy agent of importation of smallpox, quite
recently. The disease spread and prevailed epidemically in a very fatal
form, and he became odious under the imputation, as his printed statement
expresses it, of "recklessly sowing the seeds of the most contagious and
loathsome of maladies, by freely mingling with the people while knowing
that he carried the deadly infection about his person." He affirms that he
returned home from New York in perfectly sound health ; that being
attacked a few days after with a slight illness, accompanied by an eruption on
his face and body, he consulted an "eminent physician," who unhesitatingly
pronounced the eruption to be chicken-pox, and told him he might resume
his business without fear. "Nor did the idea of smallpox once cross my
mind until, after my own child had caught the infection in an aggravated
form and fallen a victim, the physicians began to whisper the dreaded
name."

The preponderance in number of what are called "negative facts," ex-
amples of innoxious presence and prevalence of varicella, should never be
allowed to lull our caution to sleep. No prudent practitioner will fail to
watch attentively the course of chicken-pox in any group or collection of
unprotected subjects. I do not believe it to be possible to diagnosticate
from it by any definable marks some of the irregular varioloid affections,
which yet are potential in spreading smallpox ; and even those who con-
tend most peremptorily for precise distinctions, allow that we do meet with
a "confounding" similarity. Where there exists any doubt, we should
have prompt recourse to the most immediate protective measures.

Nor must we entirely pretermit the consideration of another possible
origin or development of smallpox. Its identity with vaccine is at the
present day the received doctrine with the majority of our profession. I
will neither affirm nor deny it, but proceed, ex ahundante cautela, to draw
from it a practical inference. If it be true that vaccine is a modified or
degenerate variola, altered in its features and history by transmission into
and through organisms of lower type, it would be difficult to imagine why
it should not, when restored to its original nidus and pabulum, resume,
under fostering contingencies, its orif^inal characteristics. Some startling

1862.] Dickson, Smallpox. 61

examples have occurred, as not long ago at Richmond, of the introduction of
smallpox with matter supposed to be vaccine, and the explanation has been
accepted that an unfortunate accidental mixture of the two contagious
viruses had taken place. No one now doubts that vaccine may arise spon-
taneously in the cow; Jenner thought, erroneously, that it depended upon
an equine affection, "the grease ;" Baron and Ceeley have attempted to
prove that they are both variolous. And even if with Gregory we dissent
from their conclusions, and accept with him the views of Greaser, we do
not escape from reasonable fear of possible danger : if "a, morbid poison
applied to different animals produces, not a similar and specific disease, but
the disease to which the animal from constitution and structure is predis-
posed." ''Equine matter, vaccine lymph, variolous matter — each, when
applied to the vessels of the cow, develops vaccinia," says Gregory. It
would be difficult to show, upon this view, why, when applied to the
vessels of the human subject, they should not develop smallpox.

And what shall we say of cases in which " there is a general eruption of
Yaccine Vesicles over the body, resembling, in some patients, those of
Varicella," as we find it stated in the notes to Gregory's excellent work on
Eruptive Fevers. To the small number of these hitherto recorded, I will
add one from the pen of a physician, himself the subject. It is described
in the following extract of a letter to me from Dr. Henry H. Cone.

I was inoculated in the year 1815, by Dr. Samuel B. Woodward, of Weathers-
field, Conn., immediately after having been somewhat exposed to the contagion
of smallpox. The vaccine matter was inserted in two places, about the middle
and anterior part of the left arm. At the usual time the genuine symptoms of
cowpox made their appearance, such as the gradual formation of pustules which
continued to increase until they had attained the usual size. Along with the
two pustules, which formed at the places where the virus was inserted, were
three others on different parts of the body, which were a day or two later,
according to the best of my recollection. One of these was situated on the
right arm at its upper and anterior part, forbidding the possibility of its coming
in contact with or originating in the direct application of the virus ; another
was situated on the right thigh ; the third on the parietes or surface of the abdo-
men. The three last mentioned pustules were in no respect different from those
which formed at the places where the matter was inserted, neither are the
remaining cicatrices, all of them being marked with small pits or depressions
near their margins. There was some symptomatic fever ; though not so much
as to deter me from my ordinary pursuits.

In two of the instances from Gregory, the matter of the extra pustules
was experimented with and genuine vaccine resulted. I will confess to
some apprehension, that in examples of this constitutionally eruptive im-
pression of vaccine, and especially where the pustules resembled varicella
more or less, there would be a risk of arousing the ''varioloid predisposi-
tion" of Gregory and Greaser. A " very curious case" indeed is given in
the notes above referred to, of a "constitutional vesicle" breaking out at
a distance from the points at which the matter vras inserted ; the " three
incisions" made there healing up without effect. An instructive example

Dickson, Smallpox.

[July

is given in the same place, of the similarity of various eruptions, enough,
surely, to account for much "confusion" and many mistakes.

A child eighteen months old, vaccinated a fortnight before, had well charac-
terized vaccine vesicles on the external labia, and also on the perineum and
about the anus. The vesicles bore some resemblance to certain forms of vene-
real eruption appearing about those parts in children and the case was carefully
examined in reference to this point.

All such irregularities deserve special study. So also does the retarda-
tion of the vaccine influence within the system, where it sometimes remains,
holding by a tenure very obscure. Not to dwell on mere delay of the local
and general effect of the insertion of the virus, which is stated in various
instances to have lasted from 1 4 days to six months ; we may refer to an
example of very peculiar character, related in detail by Dr. Ruprecht, of
its renewal or relapse after several years' interval.

A girl of 14, being seized with influenza, complained of pain in each arm at
the spots where, when an infant, she had been vaccinated ; and in these locali-
ties vaccine vesicles became perfectly developed. An elder sister was revac-
cinated with the lymph hence obtaioed; beautiful vesicles formed, and ran a
normal course. — Yide Brit, and For. Review, April, 1850.

3. When smallpox shows itself without obvious infection derived from
a specific instance previously developed, the apparent exception must come
under one of the heads already discussed. It does not seem to me to affect
the question, if we admit the fullest efficiency that has ever been supposed to
belong to what is called "Epidemic influence," unless this influence can be
shown to act independently of the presence of a case or cases previously devel-
oped. Nothing can be more vague than the familiar use of the above phrase.
Every one is aware that all diseases prevail with greater promptness, their
causes known and unknown act with greater efficiency, over wider spaces,
and include larger numbers, at certain periods than at others. It is pro-
bable, indeed, that any malady may find in atmospheric contingencies
favouring elements ; but these are favouring, fostering, not generative.
We must not confound the parent with the nurse. Diseases both conta-
gious and non-contagious thus become epidemic. It is noticeable, too, that
epidemics vary, at different times, in their degree of malignity or propor-
tional mortality, which is not, by any means, in uniform correspondence
with their extent or sway over numbers. Prof. Wood has pronounced it
"highly probable that the epidemic influence maybe alone sufficient to
produce smallpox, scarlatina, and other contagious eruptive affections,
without the co-operation of the specific contagion." Even if the idea be
correct, the expression here used is too strong. It can hardly be said that
anything is highly probable, unless some good reason can be given for the
belief that it has once occurred. I have admitted the possibility of such
an event ; but it would be an incident both rare and mysterious. No one
would say that he expected or anticipated it under any contingencies which
he could describe or define. Epidemic influences, ex vi termini, act upon a

1862.]

Dickson, Smallpox.

great many simultaneously. Influenza, cholera, &c., are known to affect
numerous subjects at once. On the contrary, the obscurely induced attacks
of smallpox have always at first, and generally altogether, been confined
to a single individual, with whom the affair may end ; or it may subse-
quently spread more or less widely. We have agreed to stigmatize "the
absence of an efficient system of protection as a national disgrace, almost
a national crime." The appropriateness of this sentiment, it ought to be
added, must entirely depend upon the feasibility of such protection. If the
origin and spread of smallpox be probably ascribed to any unintelligible
and uncontrollable mode of causation, and such are all epidemic influences,
then there is neither disgrace nor crime in the failure to protect. Believ-
ing, however, as I do, that the introduction and propagation of this pesti-
lence are well enough understood for all practical purposes, I do regard all
governments as responsible for the institution of proper and relevant efforts
at prevention and circumscription, and deeply guilty when this is neglected.

Smallpox propagates itself, or is propagated, 1. By actual inoculation,
insertion of the virus. 2. By contact with the sick. 3. By near approach
or immersion in polluted air. 4. By fomites, either applied directly to the
surface, or acting through the air about them. 5. By diffusion of infec-
tious matter through the atmosphere to an undefined extent ; which con-
stitutes, doubtless, the chief, if not the exclusive, element, in epidemic
dissemination. This is obviously more effective in certain atmospheric
conditions, known and unknown, often or generally observed to be associated
with ochlesis, the crowd-poison, which also gives force to the third mode,
or, indeed, ail of them. Many unfavourable hygienic conditions act
rather on the constitutions of the subjects, than by multiplying or concen-
trating or intensifying the subtle virus engendered by the pestilence.

Inoculation of smallpox is prohibited by law in Great Britain, and has
fallen into disuse in our own country. Contact with the sick is more diffi-
cult to be prevented than one would think. It is not known how soon the
subject becomes a dangerous centre of evil, nor for how long. Near ap-
proach by accident must often happen, while those ill of mild attacks, or
convalescent, are permitted to make use of public vehicles and common
paths. Civilization renders impossible the abandonment of the miser-
able sick, under any circumstances ; but it is always easy to find nurses
hardened against infection by previous attacks. Fomites are sources of
widest danger, because they are of such vast variety, and often, therefore,
unsuspected. We may refer to all garments, bedclothing, textile furniture,
such as carpets, curtains, stuffed and covered chairs, &c. The tenacity with
which such objects retain their evil potency is remarkable. A story is told
by Mills of a child dying of smallpox in its cradle. The bedclothes were
carefully washed and put away ; a year after they were brought out for the
use of another infant, born to occupy the same cradle ; this new-comer soon
took smallpox, and also died, no other instance of the disease being known

Dickson, Smallpox.

[July

to exist anywhere else in that region of country. Carriages, both public
and private which have been used for conveying the sick, are dangerous
fomites. Bank-notes handled by them are very reasonably denounced also
by Dr. Buckler, of Baltimore. The dead body itself may act very effi-
ciently as fomites. I remember a case which appears strongly in point.
During the winter of 1848-49, a young man, a member of the medical
class of the New York University, died suddenly and unexpectedly in the
night, under the care of a physician who had not thought him seriously
ill. I was invited to the autopsy, and observed, when the corpse was un-
covered, a few dark-red spots on the surface, which were supposed to be
petechial ; the principal symptoms of his attack having been gastric, with
great debility, as we were informed. The coffin was taken home to a New
England village, for burial ; where, at the funeral, some of the relatives
approached and opened it, to see the face of the deceased, before it was
inhumed. Of this number, eight were attacked with smallpox,, no other
persons in the neighbourhood being assailed. It was afterwards thought
probable that the youth had attended the wards of some hospital in the
metropolis, and had been affected with the disease which at that time was
in existence there.

I have omitted to speak under this category of books, paper, letters,
solid wooden articles, and the walls and floors of houses, as disputable ;
although there are instances, repeated often enough on the records, to ex-
cite caution at least, of the reception of the contagion through the post ;
by handling walking sticks and other implements ; and by inhabiting apart-
ments in which the sick had lain long ago, and from which all suspicious
furniture had been removed. Atmospheric diffusion is, however, by far the
most injurious method in which this, like other forms of pestilence, propa-
gates itself. Nothing in nature can be more obscure or hard to apprehend
than the varying conditions which surround us, all of them comprised
under the familiar phrase "constitution of the air," though we know not
whether they are telluric or astral, electric, or thermal; unappreciable diver-
sities, at one time indifferent to the presence of a contagious malady, at
another opposed or unfriendly, or unadapted to its spread ; again, giving
it wings, as it were, and aiding its extension ; exhibiting an evil influence
by rapid increase of the number of subjects attacked on certain occasions ;
and on others, by impressing a peculiar character of violence and malig-
nity upon a narrower range of prevalence. Against this danger, so stealthy,
so impalpable, no ordinary precautions are of any avail, whether personal
or hygienic. Of the first forty cases which I saw in New York during
the epidemic of 1848-49, there was not one who was conscious of having
approached a patient affected with the disease, or who, upon close inquiry,
such as it was my habit to make, could be brought to recollect having
placed him or herself in circumstances of any imaginable suspicion of
risk.

1862.]

Dickson, Smallpox

Happily, we are provided with special and relevant means of defence,
applicable alike in all the varying conditions above enumerated and alluded
to, and available against all the several modes of extension or propagation.
Among the strongest points of contrast in the histories of disease, none is
more striking than this : that certain individuals on the long catalogue
create in the constitution which they intrude upon, a propensity, or, to
speak technically, a predisposition to be more readily' affected by them a
second and a third time, and so on indefinitely ; thus it is with malarial
fevers, erysipelas, gout, rheumatism, &c. ; while certain others exhibit a
directly opposite tendency, being, as I have styled them, self-protective ;
and giving to any constitution over which they have once prevailed, a
strange immunity against their recurrence. This is the rule — broken
doubtless by exceptions — but it is the undenied rule. "Upon this peculiar
characteristic belonging to the exanthemata, is based the hope as to all
the three, the certainty as to the one under discussion, of being able to
circumscribe, restrain it, reduce it to subjection, and, if we desire, to extir-
pate it entirely.

The most ingenious speculators have offered us no plausible explanation
of this curious and fortunate fact or law. Of the various conjectures
thrown out, it may suffice to mention two wild and inconclusive hypotheses,
which have been suggested by the analogies of vegetable life and growth :
one, that every human being is born with certain elements of organic
composition, which afford opportunity or pabulum for certain morbid
changes. The pabulum of each morbid affection being once consumed, is
not again reproduced, and the changes in which that consisted cannot again
take place ; and thus, hooping-cough and measles, scarlet fever and small-
pox, and perhaps some others defend against themselves. The other hypo-
thesis is equally fanciful, and assumes that, in the course of certain mala-
dies, new products are evolved, which are permanently retained in the sys-
tem, preventive of the same actions which originated them ; as the roots
of a vegetable are supposed by some to leave in the soil where it has grown
certain effete matters or exuviae, unfriendly to its life, whence the necessity
for a rotation of crops ; or as animals even in health, fill any confined
space around them with noxious efifiuvia, demanding perpetual change of
air and involvements. The well-ascertained law or fact suffices for our
cherished purpose.

Again, it has been long known also that smallpox, which, taken "in the
natural way," either by contact, near approach, from fomites, or when
epidemically diffused, is one of the most fatal as well as repulsive of
human disorders, puts on a far milder and less malignant character when
introduced into the system by a wound in the skin, "inoculation." Asia
and Africa, the most ancient seats of this terrible pest, have long known
and still avail themselves of this mode of palliation. England resisted it
obstinately, yielded to it reluctantly, and has now fatuitously prohibited it.
No. LXXXYIL— July 1862. 5

Dickson, Smallpox.

[July

We have been indifferent to it, and act as if averse on principle to any
interference with every man's right to be poisoned at his own will. Inocu-
lation was first practised by civilized hands at Constantinople, in 1700; it
was introduced to the English and brought across the Atlantic twenty-one
years after ; and so completely superseded by Jenner's vaccination, promul-
gated in 1798, that in 1840 it was "declared illegal by the British Parlia-
ment, and offenders sent to prison," says Gregory, "with a good chance of
the treadmill." Its alleged influence in lessening the mortality of smallpox
is indeed marvellous, and scarcely credible. The author just named tells us
that "with ordinary precautions, not more than one case in five hundred
will terminate unfavourably." He denies positively, and opposes strongly,
both by fact and argument, the assumption which has prevailed widely, and
is maintained by Sir Gilbert Blane, that "it disseminated the virus, increas-
ing the foci of contagion ; and thus favoured the spread of the disease,"
demonstrating, I think, its falsity. Indeed, so much are the violence, the
suffering, and the proportional mortality of smallpox diminished by inocu-
lation, that I would advocate unhesitatingly the propriety of universal
inoculation at as early a period of life as was ascertained by repeated and
careful experiment to be safe and allowable. I would have such inoculation
repeated at short intervals, until in every subject the point of absolute inca-
pacity to receive the infection was fairly reached. This would happen in a
majority of instances with the first eflScient incision of the virus ; it would
probably take place in the rarest exceptional cases of renewed susceptibility,
after a very few repetitions. Those who had gone through this process
would be proof for the future against the pestilence, and as to them it would
be annihilated, virtually exterminated. And as all constitutional peculiari-
ties are hereditarily transmitted, whether of original organization or in any
way acquired, so this anti-proclivity or acquired immunity would go down
increasing in force with every generation, until the whole race would be-
come insusceptible of this horrid mode of dying. But this is only half my
plan.

However palliated by inoculation, smallpox would still demand and
engulf a certain proportion of victims ; and besides, would inflict in its
course a considerable amount of unavoidable suffering. With grateful
exultation we may reflect that we have in our hands a means of still
reducing, to a minimum yet more remarkable, the evil against which we
are contending. For this purpose we confidently resort to the vaccine.
Whether of identical origin with variola or not ; whether primarily a
human disease altered in course and history, clipped and abridged of its
first atrocious properties by transmission through some of the lower organ-
isms ; or primarily an equine or bovine distemper, genially adapted to the
service of our dominant race, vaccine exhibits a close and most beneficial
relation with smallpox. An enviable immortality glorifies the name of
Jenner, as having made known this invaluable relation. Although not

1862.]

Dickson, Smallpox.

self-protective, it protects in a remarkable degree against smallpox. This
protection we have learned is far from being absolute, though Jeniier
thought and pronounced it so. In his petition to Parliament (1802) it is
stated that he "had discovered a means of rendering through life the person
protected by it, 2Derfectly secure from the infection of smallpox." For
some time the public indulged the same sanguine anticipation, which, I
need not say, is now universally abandoned. I have myself attended a
pretty severe case of variola — or as some would insist on terming it, vario-
loid, in a lady vaccinated by Dr. Jenner with his own hands. In Davy's
tabular view of the Maltese epidemic, out of 8067 reported cases, 2720 are
set down as "supposed vaccinated," and 390 as "well vaccinated." But I
will not dwell on this point. As a protective, vaccine employed alone has
failed. Perhaps the same failure may be as truly affirmed of inoculation
employed alone. In Davy's tables, 97 are set down as "having had small-
pox before." He mentions as authentic the case of "a lady, mother of ten
children, who had smallpox eleven times ! first in infancy, and afterwards
when each of her children had it; these last being as severe as the first."
The books abound with similar statements. It is certain that particular
constitutions admit one or the other of these analogous affections, and yet
not both. A case is mentioned in the British and Foreign Review,
October, 1859, where vaccination was attempted many times in vain ; the
patient had smallpox severely at the ages of twelve, forty-three, and forty-
five. What would have been the effect in such an instance of early inocu-
lation, repeated, as I have proposed, at short intervals, to exhaust the
proclivity or susceptibility? There is a difference in this respect in races
as well as individuals. The Easterns are very susceptible of smallpox ; but
I have heard one of the American missionaries to Siam assert that for
seventeen years they were foiled in every attempt to introduce vaccine
among the willing people. Some systems repel both contagions. I vac-
cinated many times and inoculated repeatedly with variolous virus, all in
vain, a young lady. She afterwards nursed with impunity a sister ''sup-
posed vaccinated," who died of confluent smallpox ; this latter had never
been my patient.

Now, if the reader has given me his patient attention, he will, I am dis-
posed to think, agree with me that each of these two inestimable methods
of protection is unfortunately imperfect, insufficient when employed alone,
and undeserving of our full confidence. Regarding them as complements,
each of the other, I would institute the employment of them both. Vac-
cine is the most certain in its action as a modifier. In all the tables we
find the proportion of deaths in smallpox after vaccine set down as smaller
than among those who are marked as "having had smallpox." Yariola is,
on the other hand, the more efficient preventive or protective. By the
resort to both of them, we obtain the double advantage of uniform pallia-
tion, and more certain protection, or obliteration of original susceptibility.

Dickson, Smallpox.

[July

Gregory tells us that smallpox in the unvaccinated is five times more
fatal than it is to those who have previously undergone vaccination." The
latter should, therefore, precede the former. Revaccination, at distant
intervals, better regular, of course, than irregular or capricious, can have
no advantage over the plan proposed. It is uncertain whether it ever does
away the susceptibility to its own reception. Many series of experiments
are required to decide this point, and I know of none but those made by
Dr. Darrach, of this city, which have not been repeated. I think we have
reason to doubt whether in all individuals any number of revaccination s
w^ould be securely protective ; wisdom inculcates the course of greatest
safety, which consists in following up vaccination by inoculation, especially
if we repeat the latter to exhaustion of susceptibility. The experienced
practitioner last quoted, and so often referred to as high authority, goes on
saying, "I inoculated three of my own children, at the ages of twelve, thir-
teen, and fourteen, after successful vaccination in infancy, and the result
was as follows : in two, local affection, without any fever or eruption. In
the third case, there was local affection without fever, but with papular
eruption on the seventh day, not advancing to vesicles. I firmly believe
that these children are now and will remain through life unsusceptible of
smallpox." In this belief I fully accord with the writer, and entertain
strongly the opinion that there is no other way of obtaining such complete
security.

Let me refer again to the "report" of Dr. Jewell. "In a former report,"
says Dr. J., "I have alluded to the inadequacy of voluntary provision to
secure us from the ravages of smallpox, and I have elsewhere asserted that
nothing less than a compulsory law, with a penalty attached for its viola-
tion, would prove an effectual barrier, &c." What then shall be done?

There are two difficulties in the way of efi&cient action here. The first is
the universal vis inertise, opposed not only to all innovation, but to all
movement of any kind. Yet if the medical profession were as a body to
engage with earnestness and zeal in their duty, the great inert public might
be roused, and much good be effected. But at best this would be only a
partial success. I am satisfied that the inattention, indifference, and inac-
tion of even the most enlightened communities as to this matter, are owing
to their want of clear conviction, their imperfect trust in the security attain-
able by the measures urged ; and this is the second and greatest difficulty
before us. Nor can such incredulity be considered unreasonable, when we
reflect upon the vacillation, the avowed scepticism and open opposition of
experts, and men of weight, influence, and knowledge, both in and out of
the profession. Recollect that opportunity has never been given for the
attainment of confidence, Chatham's "plant of slow growth," in any of the
means brought to their view. Inoculation was from the first unpopular
and scouted by those who feared to try a new method, involving a reluctant
familiarity with a dreaded enemy. When it had just outlived opposition,

1862.]

Dickson, Smallpox.

it was supplanted by vaccination, which promised so much, and was at the
beginning so fortunate. But soon, very soon, this good fortune came to
an end, and the exaggerated promises were found to be unfulfilled ; and
disappointed faith shrunk into doubt and disbelief. I do not despair of
reviving the spirit of earnest inquiry and active experiment. The evil is so
great in the present, and so menacing for the future, that if physicians will
everywhere unite upon some system, we may reasonably hope to obtain from
the constituted authorities the inauguration of some effective measures of
coercion. A sense of the necessity of harmony among ourselves should
lead to rational compromise and unity of effort. There are among us some
who place little reliance upon the protective power of vaccine ; there are
some who dread the presence, in any form, of variola. None of us, so far
as I am acquainted with my brethren and their opinions, none of us doubt
the self-protective immunities of smallpox, or the happily palliative, modi-
fying tendency of vaccine. Let us then with energy, perseverance, and
unanimity recommend to all civilized governments the combined employ-
ment of these two safeguards. Let us procure that it shall be ordained
that every child shall undergo vaccination by some expert within a month
after birth ; that as soon as the constitution shall have gone through its
influence, inoculation with variolous virus shall be performed, and that this
latter operation shall be repeated again and again at brief intervals, until
all reasonable satisfaction has been attained, of the entire extinction of the
susceptibility to smallpox.

I am aware that there are some, even among my friends, who will regard
all that I have written as mere Utopian speculation. Others will foresee
invincible obstacles in the details necessary to carry out any plan which
may be instituted. To the former I offer my entreaties that they would
lay aside their inactive scepticism and join in the labours of more hopeful
or sanguine philanthropists. I might say to the latter that I have not
found it difficult to prepare a series of ordinances, which I refrain from
presenting to them, partly because it would occupy too much time and
space ; but for the still better reason that when it is once determined to
act in the premises, the first step of such action ought to be a careful and
deliberate consultation as to the modus operandi. I shall consider myself
one of the most fortunate and happiest of men, if I prevail in arousing my
medical brethren and my fellow citizens to some determined and general
effort at the restriction, palliation, and extermination of one of the most
enormous evils which afflict our common humanity.

TO Lente, Amaurosis and other Disorders of the Eye. [July

Art. IY. — Amaurosis and other Disorders of the Eye, resulting from
Injury of the Terminal Branches of the Fifth Pair of Nerves. By
Frederic D. Lente, M. D., of Cold Spring, New York.

That lesion of the fifth pair at some point within the skull, or of that
portion of the cerebral substance from which they take their origin, will
cause a disturbance, more or less serious, of the organ of vision itself,
sometimes in its function, sometimes also in its structure, terminating occa-
sionally in its total disorganization, is a fact established as well by the
experiments of Magendie and other physiologists, as by the observations
of various pathologists in diseases of the brain.

A number of cases of traumatic amaurosis arising apparently from injury
of the external parts adjacent to the eye, which have fallen under my
observation from time to time, have induced the conviction that disturbance
of vision, resulting in asthenopia, or in amaurosis, may ensue as well from
injury of the terminal branches of the fifth pair, as from that portion which
forms a part of the encephalon.

The consequences which follow injuries about the orbit, as affecting the
eye, are referable to three heads : First, concussion, or other injury of the
brain or eyeball; secondly, development of inflammation, or other disease
within the eye, resulting in gradual impairment, or loss of vision, sometimes
even in destruction of the eye; thirdly, a sympathetic or reflex influence on
the retina or optic nerve, developed sometimes immediately, sometimes after
a longer or shorter interval, as a result of the direct lesion of the nerve
filaments, or in consequence of processes of repair succeeding the injury.
Diseases also of the periorbital region have been followed by phenomena
that have been referred to the last two heads.

Modern writers on diseases of the eye devote but little attention to this
subject, and generally refer the disturbance of sight and other sequelae to
the first head — that is, direct injury of the eyeball or brain ; in some
instances also, to the second head. Thus, Lawrence, Middlemore, Sichel,
Tyrrell, Wharton Jones, Haynes Walton, Mackenzie, all seem to be more
or less inclined to this opinion. The latter, who enters into the discussion
of this subject, especially in his later editions, more extensively than the
others, after relating many instances, as we shall presently see, very plainly
indicating the nervous injury as the direct cause of the affection of the eye,
yet concludes his remarks by saying that "the consideration of these facts
naturally leads us to regard with still greater doubt the alleged occurrence
of purely sympathetic amaurosis from slight injuries of the fifth pair, and
to suspect that, in the supposed cases of this sort, there has been, in addi-
tion to the external injury, either concussion of the eyeball, or disease
excited within the cranium." The first case which we shall relate, and

1862.] Lente, Amaurosis and other Disorders of the Eye. 71

which occurred nearly twelve years ago, during my residence as house sur-
geon in the Xew York Hospital, led me to adopt a different opinion; and
a further investigation of the matter only confirmed this opinion. My
attention has lately been recalled to this subject by the publication, in the
American Medical Times for March 15, by my friend Dr. Noyes, of the
New York Eye Infirmary, of a similar case, to the extremely interesting
history of which I shall hereafter advert ; also by some interesting com-
mentaries on this case in a succeeding number of the same journal, by M.
Echeverria. The matter has been invested with a medico-legal interest in
consequence of the publication of the report of a trial in the last edition
of Walton's Treatise on the Eye. Dr. Walton and several other surgeons
of note were employed by the London and Northwestern R. R. Co., who
were sued for heavy damages by a watchmaker, who had received a very
trivial injury about the eye, but who subsequently became in a measure
incapacitated for his particular occupation in consequence, as was alleged,
of this injury. ** The question of amaurosis, depending immediately or
ultimately upon injury of the nerve, was raised by the patient's counsel."
I am now quoting from Dr. Noyes' article: "Mr. Walton testified that in
his opinion ^mere injury of the nerve-branch on the head can have no
effect on the function of the retina; that loss of sight, when associated
luith such lesion, is due to coincident lesion of the eyeball.^ The plain-
tiff's counsel referred to numerous cases recorded by authorities, disproving
this opinion, and the chief justice seemed to be particularly severe on these
records. The medico-legal bearing which, as we see, this question may
assume, would, of itself, render a full investigation important; for, the
cases recorded in this paper, taken in connection with the evidence scattered
among the various authors on diseases of the eye, which we shall presently
endeavour briefly to collate, will, in our opinion, go far towards invalidating,
if indeed it does not completely annul this decision of Mr. Walton. But,
we shall also find that the discussion will have a practical bearing on the
treatment of certain affections of the eye. We indulge the hope, therefore,
that though this paper may prove tedious in some of its details, it may not
be entirely unprofitable.

-Case I. Antoinette H., 11 years of age, an interesting and intelligent
girl, was brought to me at the hospital as an out patient on the 6th of
July,. 1850. On the 4th a boy snapped a percussion pistol near her; and,
a fragment of the copper cap flying off, struck her in the face. There was
a small wound on the left side of the forehead near the median line, which
bled freely for a time, but caused little pain. But little concern for the
injury was felt at the time; but, on the day following, the little girl com-
plained of severe pain in the right eye, and around the right orbit, of a
"numbness^^ extending from the ivound on the left side of the forehead as
far as the right temple, and also of dimness of vision of the right eye. All

1 The words are Dr. Walton's ; tlie Italics are mine.

72 Lente, Amaurosis and other Disorders of the Eye, [July

these symptoms have been increasing to the present time, especially the
last. The right eye is now amaurotic, patient having but little more than
the perception of light; being unable to distinguish with it even large
objects near her; patient seems rather disinclined to face the full light of
day. • The pain in and around the eye is quite severe, and is much increased
hy pressing upon the seat of the wound of the forehead. At this point,
vy^hich is a little to the left of the median line and about half an inch below
the line of the hair, there is the appearance of a slight abrasion of the
cuticle, and a small circumscribed induration, as if from effusion of lymph ;
no foreign body can be felt. There is a slight redness of the right eye.
Patient is of nervous temperament, and in rather feeble health; was in
Paris during the late revolution there, and her nervous system received a
shock from which it has not yet recovered. Judging that a piece of the
copper cap had lodged in the forehead, and had originated and was main-
taining the amaurotic symptoms, I determined, with the concurrence of my
colleague, Dr. W. H. Church, now one of the surgeons of Bellevue Hos-
pital, and medical director in the Army, to search for and remove it. After
making an incision, and searching for some time, we found, imbedded firmly
in the pericranium, a jagged fragment of cap, w^hich we removed. During
the somewhat protracted exploration of the wound, patient complained of
very severe pain extending from it, towards the right eye, and in the right
eyeball itself. Immediately after the removal of the fragment the pain
abated, was less than before the operation, and vision was in a great mea-
sure restored, patient distinguishing even small objects without difficulty.
Both Dr. Church and myself were much surprised and gratified at the un-
expected success of our little operation. Directed quietude, low diet, a
gentle laxative, and the application of a cooling lotion to the eye.

July t. The "numbness" complained of as affecting the right side of the
forehead, has there abated, and has extended to the left temple. The left
eye also is painful, slightly injected, and vision somewhat impaired. The
inflammatory symptoms of the right eye have much increased; the pain in
the globe is deep seated, and increased by pressure; vision of this eye still
better than it was before the operation, but not so good as it was just after
it. Skin and pulse natural; bowels open. Directed leeches to temples,
and mercurial and anodyne ointment around orbits ; rest in bed in a mode-
rately darkened room.

8^/?.. Slept little last night. Complained of increased pain in right eye,
and around the orbit; complains also of "soreness" over the whole scalp.
There is now only very slight anaesthesia on right side of forehead, and
that on the left side has not increased. Directed emplast. lyttae post dext.
aur. Anodyne at bedtime.

9)th. In the early part of the evening the pain became much aggravated,
extending over the forehead, scalp, and right side of the face; the right
cheek also, over the lower jaw, became swollen, and tender to the touch.
The pain was repeatedly relieved by the tinct. aconite. Anodynes rejected
by the stomach. During the night, complained of coldness and numbness
of the extremities; this was relieved, after a time, by sinapisms, and she
slept during the latter part of the night. This morning, feels tolerably
comfortable. Pulse and skin still natural. Has now no uneasy sensations
in the left eye, and vision with this eye nearly perfect. The anaesthesia on
this side has also nearly disappeared. The pain in right eye and around
orbit increased; vision about the same. The tumefaction about the lower
jaw still exists to some extent. Continue treatment.

1862.] Lente, Amaurosis and other Disorders of the Eye. 73

llfh. Was called to patient last evening, and found her apparently suf-
fering greatly with neuralgic pains in the face, neck, and chest; the slightest
pressure on the integument aggravating the pain. The pain in the back
of the neck is described as being the most severe; and there is inability to
flex the head; jaws swollen slightly, and spasmodically closed; skin hot,
pulse frequent; some difficulty in micturition; had vomited several times ;
complained also of her hands being asleep. Ordered sinapisms to feet ;
tinct. opii camph. with valerian pro re nata. This morning is quite com-
fortable. Fell asleep after one dose of the medicine, and rested quietly.
Pain in the eye much abated ; no pain elsewhere : skin pleasant, pulse
natural.

12th. Improving; no exacerbation of pain last night. Can read tole-
rably fine print with the right eye.

13th. Last evening was again attacked with the neuralgic symptoms ;
temperature of skin not much increased; pulse slightly accelerated. Ap-
plied the aconite, and gave one dose of the antispasmodic mixture, when
she fell asleep. Tongue much furred ; is quite feeble ; has a voracious
appetite, but is not indulged. Chicken soup, with farinaceous food, R.
Hydr. submur. gr. v hor. s. ; ol. ric. mane; quiniee sulph. gr. i ter die.

14^7?. Better; "quite welF' s/?e says. Has been moving about the house,
against orders. No pain in eye. Directed some meat, and quin. sulph.
gr. V, at 2 o'c. to ward off another paroxysm. Hor. som. hydr. c. creta
gr. V ; ol. ric. mane.

16th. Had a slight exacerbation last night ; complained of pain in the
right eye, but it extended no further. Eye looks perfectly natural, with
the exception of slight injection of the sclerotica, which is fast disappear-
ing. Some asthenopia, and increased lachrymation.

11th. Last night had another violent attack of pain in the eye, but no
other neuralgic symptom. The quinia was omitted by mistake yesterday
afternoon. The eye looks much worse, and vision is much impaired. R.
Leech to Schneiderian membrane.

19//?,. Doing well ; repeat leech.

21st. Eye now appears to be normal, but is weak. Continue quinia and
wear a shade over the eyes.

30//?. Health improving ; vision perfect ; pupil acts well.

December 14. My little patient called on me to-day. Seems quite well ;
the eyes have a perfect appearance, but she has, with the right, visus dimi-
diatus. Lost all traces of her after this date ; heard that she had removed
to Philadelphia.

Taken in connection with the above, the following cases, reported in
1842-43 in the London Medical Gazette, by the late Dr. W. C. Wallace,
a skilful and well-known oculist of New York city, which I take the liberty
of transcribing entire, are extremely interesting : —

Case II. Patrick Burns, 35, stonecutter, on the 8th Oct. was attacked by seve-
ral men, knocked down, and wounded over the right foramen infra-orhitarium.
The wound gave so little trouble that in two days he went to work. Ten days
after, the vision of this eye became indistinct; and, imagining that the dimness
was occasioned by the scab, he picked it off, though without the least improve-
ment. He was soon obliged to abandon .work altogether. The sight of the
affected eye became so obscure that he could not make out an object; though,
when the hand was passed across the eye, he could tell that there had been
something before it. On the 13th November, when I first saw the patient, I
dissected out the cicatrix, which was unusually prominent ; and, on cutting it

Y4 Lente, Amaurosis and other Disorders of the Eye. [July

open, I observed in the centre a small piece of steel. R. Strych. gr. vj : alco-
holis ^ij ; acid. acet. gss. M. Fricentur tempera m. et n. Pil. cal. et colocynth.
17th, wound nearly healed, and vision much improved. He can now see the
fingers held before the eye. He can, but with much difficulty, distinguish large
letters, and expresses himself as relieved of uneasy sensations about the side of
the head.

Case IH. John Williams, 25, butcher. On the 8th of November, during an
election riot, received, from an unknown weapon, a wound on the right lower
eyelid, helow the edge of the orbit, and midway between the foramen infra-orhit-
arium and tendon of orbicularis palpebraru7n. According to his own account,
both eyes immediately became blind, and he had to be led home. As, on the
second or third day, the vision of the right eye was perfectly restored, he thinks
that the temporary deprivation of sight was caused by the tumefaction of the
lids. Since the injury, the left eye has been completely amaurotic. With this
eye he cannot recognize the least ray of light, and is even insensible to the glare
of a magic lantern. The iris is somewhat expanded, and totally immovable
when the other eye is closed, but when both are open, their motions perfectly
correspond. With the exception of the cicatrix under the right eye, and the
total loss of vision in the left, there is no appearance of disease. With great
difficulty I persuaded the patient to allow me to remove the cicatrix, which was
found to contain a smcdl foreign body. But, by no entreaty could I persuade
him to allow me to bring the edges of the wound together by stitches. Although
he promised to return, he never afterwards made his appearance, and I have not
been able to find any traces of him.

Happening to mention these cases to the late Dr. J. Kearney Kodgers,
then one of the surgeons of the New York Hospital, and one of the founders
of the New York Eye Infirmary, he related a case in point, which had fallen
under his own care. The notes of this case I have unfortunately lost, and
cannot therefore give its very interesting history with accuracy; but, as I
now remember it, the substance was the following : —

Case IY. A little girl, five or six years old, the child of a friend of the
doctor, was playing under a table ; and, on rising up suddenly, struck her
head against the edge of the table. Some time after this it was noticed that
vision of one eye was becoming very imperfect, and Dr. Rodgers was con-
sulted. The blow on the head was not, at that time, considered by the
parents as having any connection with the disorder of vision, and was
therefore not mentioned. But the doctor, on running his hand over the
head of the child, in examining the eye, noticed that she flinched w^hen he
touched a particular spot of the scalp ; and the mother then said that, in
combing the hair, the child often cried when the comb came in contact with
this spot, and then related the history of the accident. On closer exami-
nation a cicatrix was discovered, and was excised. After the wound had
healed, vision was either much improved, or rendered perfect, I cannot
distinctly remember which. But the doctor regarded it as a remarkable
circumstance.^

' These cases, and others wliicli will be alluded to, bear out one of the conclu-
sions arrived at by Doctor Skokalski in bis investigations concerning the functions
of the fifth pair, viz., that "sight does not depend solely on the retina, but on a
combined action of the retina and fifth pair." Comparative anatomy also furnishes
us with the important fact that, in s'ome animals, whose visual apparatus is -but
slightly developed, the optic nerve is wanting entirely, and its place supplied by
a branch of the fifth pair ; as in the mole tribe ; but most unequivocally, in the
proteus anguinus.

1862.] Lente, Amaurosis and other Disorders of the Eye. 75

Remarhs. — Hippocrates remarks, ''The sight is obscured in wounds in-
flicted on the eyebrow, or a little higher" (Middlemore). Beer makes a
similar observation, and relates several cases in support of his opinion. He
says that ''he has had frequent opportunities of accurately observing and
curing amblyopia and amaurosis, occurring in consequence of wounds of
the eyebrows." Also, that "where such wounds are judiciously managed,
and speedily healed by adhesion, no bad consequence ensues ; but when
suppuration occurs, followed by the granulating process necessary for
secondary union, the divided nerves are involved in the inflammation, and
subsequently included in the hard cicatrix, and, as he conceives, compressed
and irritated.'" Larrey seems to have had the same idea, for he says, "In
incisions about the orbit, we should avoid, as far as possible, injury of the
ramifications of the frontal nerve; or, if we injure it, we should be careful
to make a complete section." And, as Middlemore remarks, "few surgeons
have had a greater extent of experience in this particular form of injury."
Middlemore himself records a number of interesting cases of amaurosis from
orbital wounds ; though he appears to be somewhat sceptical as to whether
it should in general be attributed to the lesion of the nerve. He says,
"Amaurosis may arise during the period of dentition ; it may take place
from the irritation of a carious tooth ; from laceration, or other injury of
the supra-orbitary nerve." He relates a case in which Mr. Howship
removed an encysted tumour from the scalp, which produced ^'marked and
permanent improvement in vision.^'' Another case, in which M. Demours
removed a tumour from the neighbourhood of the eye, and thus produced
amaurosis. Another from the Edinburgh Medical and Surgical Journal,
"which would appear," he says, "to prove that wounds of the infra-
orbitary nerve may restore the sight of an eye which has long been lost
from an amaurotic affection." "A man was affected with perfect gutta
Serena of the right eye, and had the sight of the eye restored, he thinks, in
consequence of receiving a smart blow in the neighbourhood of the infra-
orbitary nerve of the right side of the face." Another still more striking
case, in which a person received "a wound just above the right eyebrow
from a piece of glass, which was removed immediately after the accident."
When the wound had healed, "the sight of the right eye was very nearly
lost; he had a painful sensation in the neighbourhood of the cicatrix, and a
singular sense of creeping, and pinching and quivering of the upper eyelid
and the integuments of forehead." "I made a free incision of the cicatrix
down to the bone, and all uneasiness at once ceased, and the eye, shortly
after, assumed its healthy character and functions, and vision was perma-
nently restored.''^ Lawrence, after relating two or three cases of amaurosis
following wounds and the formation of cicatrices over the brows, remarks,
"It is still a matter of doubt whether injury of the frontal nerve may cause

' Lawrence, American edition, 1854, p. 124.

76 Lente, Amaurosis and other Disorders of the Eye. [J^ily

amaurosis." Aud yet, he adds, "injmy or other irritation of the trigeminus
may bring on impaired vision or amaurosis." "The sympathy between the
trigeminus and the immediate nervous apparatus of vision affords the only
explanation of some apparently obscure cases, in which amaurosis seems to
have depended on a carious tooth, or on some other local affection seated
in the head." (Op. cit.,p. 578.)

The following remarks by Marshall Hall were reported in the London
Lancet for 1837-38. "These experiments," alluding to those made by
Magendie, "are not the only evidence we possess of the influence of the fifth
pair on vision." "In an interesting case under my own care, a partial
amaurosis of the right eye has arisen apparently from the caries of the
upper canine tooth of the right side." It was augmented by unsuccessful
efforts at extraction. It has not ceased, however, since extraction was
effected. "These facts," says he, speaking of this and other cases, "with
the similar results from wounds or tumours of the supra-orbit-ar branch of
the fifth, appear to me to confirm the extraordinary experiments of Magen-
die." Hennen says,"^ "I have met with one or two cases of amaurosis from
wounds of the supra-orbital nerve." "Scarpa," he says, "doubts of the
possibility of the cure of amaurosis from this cause, and mentions Valsalva's
case as the only one on record. Mr. Hey, however, states another in the
Medical Observations and Inquiries, vol. v. M. Larrey mentions another,
Yicq d'Azyr, who gives a case of amaurosis from a wound of this nerve, in
the Histoire de la Societe Royale de Jledecine, Annee 1776," says he has
" since divided this nerve in quadrupeds, but without producing any such
effect."

That defective vision may result as the direct consequence of irritation
of the terminal branches of the fifth pair may also be inferred from the
effects of remedial applications to these nerves, and from the phenomena
observed to follow irritations and injuries of other branches not so imme-
diately connected with the eye. Some of these instances it will be proper
to mention. A friend of the writer, a distinguished surgeon of Xew York
city, was incapacitated for business by violent neuralgia of the face; after
having suffered some time with it, he noticed that one of his molar teeth
was defective, and went to a dentist to have it examined ; not supposing,
however, that it had any connection with his neuralgia, since it gave him
no pain ; its removal was advised ; the operation was scarcely over before
the doctor experienced complete relief from his excessive pain. "I felt,"
he said, "as if I could have shouted for joy." A lady, a short time since,
applied to me to extract a tooth for her little daughter, which, she said,
had been causing her excruciating pain day and night ; but, on examina-
tion, I could discover no defect ; and prescribed some anodyne remedy,
which gave only temporary relief. A dentist was called in, who also de-

' Principles of Military Surgery, 2d Edin. ed., p. 346.

1862.] Lente, Amaurosis and other Disorders of the Eye. 77

clined extracting a sound tooth ; but on a second visit, and a closer exami-
nation, detected an unsound tooth at some distance from the offending one,
and extracted it. The pain instantly ceased, and did not recur. Mackenzie
relates a remarkable case in point. A man had violent neuralgia of the
eye, soon succeeded by amaurosis, and continuing, notwithstanding various
treatment, from the autumn of 1825 until the beginning of 1827. At this
time M. Galenzowski, to whom he applied, ''found vision of the left eye lost
and the pupil dilated. He extracted a decayed tooth from the left upper
jaw, and, to his astonishment, and that of the patient, found, attached to
its root, a splinter of wood, supposed to have been originally attached to a
toothpick of wood. Nine days after, tlie patient had entirely regained his
sigM.^^^ Mackenzie relates another equally remarkable case, occurring in
the practice of Doctor Yan Zandt, of St. Louis, ''of a young man affected
with complete amaurosis, excited by the persistence of two deciduous teeth.
As S0071 as they were extracted the patient looked up as if terrified, Siud found
his vision restored.^' "Morgagni, Notta, Deval, Taviguot, and others,"
says M. Echeverria, "have known amaurosis to be caused by neuralgia, and
to disappear as soon a.s the neuralgia was cured." (The Italics in the
above references are my own. — L.) Such cases as these might be multi-
plied, but it is scarcely necessary. ^

As regards the illustrative effects of the application of remedies above
alluded to, I will adduce the following case : —

Soon after the occurrence of Case I, I was led to try the effect of the
application of electricity by induction to the orbital branches of the fifth
pair for defective vision, apparently not depending on internal disease of
the eye (the ophthalmoscope had not then come into use). An old sailor
in one of the upper wards of the south building of the N. Y. Hospital, had
recently become so amaurotic that he was unable to distinguish anything
but large objects about the room. I applied the poles of the apparatus to
the supra and infra-orbital branches respectively, and continued the appli-
cation for near half an hour daily. After two or three days, he noticed
improvement of vision ; could distinguish a stovepipe hole in the wall, which
had before been invisible to him. Subsequently he could read the large type on
the cards hanging on the walls ; and eventually the large type of a book.^

Dr. Addinell Hewson, lately of Wills' Hospital, published a year or two
since a number of cases of complete relief of the most intense photophobia,
by one or two applications of electricity to the orbit ; he alleges almost
invariable success. In this connection I will quote the following paragraph
from a lecture by M. Echeverria, published in the American Medical Times,
for May, 1861 : "In applying electricity to the eye, you should always be
aware of the nature of the current to be employed." "An unfortunate
accident happened to the celebrated Duchenne de Boulogne, who, not know-

1 Arcliives Generales de Medecine, tome xxviii. p. 261. Paris, 1830.

2 [For other cases see Lawrence's Treatise on Diseases of tlie Eye, edited by Isaac
Hays, M.D., Philadelphia, 1854, pp. 61G-618.— Ep.]

2 Magendie proposed galvanism for the amaurosis succeeding injuries of the orbit.

t8 Lente, Amaurosis and other Disorders of the Eye. [Jidy

ing the effect of the continuous current upon the optic nerve, applied it to
a patient afflicted with paralysis of the facial, and caused the already men-
tioned mischief (loss of sight)." I have, however, in one case applied the
continuous current daily, for two or three weeks, to the orbital nerves for
weakness of vision, with good effect.

Since writing the above, my attention has been called to a report of
cases treated at Wills' Hospital, for Diseases of the Eye, in 1839, by the
editor of this journal,^ from which I quote the following extracts, as bearing
on the effects of injury of the supra-orbital nerves, and on the effects of the
galvanic current. It will be observed that Dr. Hays' experience agrees
with my own with regard to the effect of the continuous galvanic current.

Case. Imperfect Amaurosis of Bight Eye from a Blow — Bartial Be-
covery. — Abraham Corbit, 41, admitted Oct. 5, 1839. Nine days ago,
whilst splitting wood, a piece flew up and struck him on the right eye. He
experienced little or no pain from the blow at the time, nor did he suffer
any subsequently. Seven days after the accident he was quite blind in the
right eye. Appearance of eye perfectly natural. Patient had a variety
of local and constitutional treatment with varying success. Finally, gal-
vanism was tried by Dr. Hays with some improvement. Patient then left
the hospital, but returned afterwards in a worse condition. "The treat-
ment, to which he was now subjected, consisted in the frequent use of gal-
vanism, with the addition, after a few days, of strychnia, conveyed into
the system by the galvanic current," with some other adjuvants. "By
these means," says Dr. H., "his sight improved." He was subsequently
discharged relieved.

The following interesting observations are appended to the case by Dr.
Hays.

"Whether the amaurosis in the present instance was the result of concussion
of the retina, or of injury of the supra-orbitar branch of the fifth pair cannot
positively be determined, as it was impossible to learn from the patient whether
the blow was directly on the eye or on the brow, the injury being so slight as
not to have attracted much attention at the time, and the blow had left no mark.

" The remedy which was most useful in this case was unquestionably galvanism.
We have an evidence of this not only in the improvement which followed its
application, but in the still more striking fact, that the patient actually saw
better ivliilst subjected to the galvanic action. On the 6th of December, whilst
the galvanic current was passing from the mastoid process to the superciliary
ridge, I requested my intelligent friend. Dr. John Neill, to hold before the patient
some letters, and I asked him if he could distinguish them : he replied, * I see
better than I could.' The galvanic current was then interrupted by disconnect-
ing one of the wires from the plates, and which was done without the patient's
knowing our object. The letters being still held up, the patient in a minute or
two requested the letters to be held nearer, then farther off, and finally he ob-
served, 'I do not see as well as I did just now.' The connection being again
made, the patient almost immediately and with apparent surprise exclaimed, 'I
see better, again.' The patient was not aware of our object in this experiment,
and though of course he must have been sensible of a difference in the effect,

' See number of this Journal for August, 1840.

1862.] Lente, Amaurosis and other Disorders of the Eye. 79

still he did not know, as the poles were all the time applied to his head, that he
was at times freed from the action of the apparatus.

" In a case of a similar kind, that of J oseph M. Sutter, a carpenter, set. 43, ad-
mitted October 18, 1836, a complete cure was effected by galvanism. This man
trod upon a log, which tilted up and struck him over one eye. When admitted
he had complete amaurosis of that eye. Yarious remedies were employed,
among others moxas, with little benefit. I then resorted to galvanism, the very
first application of which was productive of marked improvement, and its em-
ployment for an hour, two or three times a week, for five weeks, effected a com-
plete cure. He was discharged January 3, 1837, well.

"In Sutter's case, and also for Corbit when he was the first time in the house,
the galvanic apparatus employed was a Cruickshank's battery of twenty pairs
of plates one and a half inches square. Subsequently for Corbit we used one
with fifty pairs of plates three inches square. When this was in full activity it
was too powerful for our purpose, and only half or two-thirds of the plates were
usually employed. The connection was made by means of leaden wire con-
ductors, to one end of each of which were soldered a slip of copper, and to the
other a hemisphere of brass, the flat surface of which was filed into grooves
crossing at right angles, so as to form a number of sharp points. Over these
were tied thin disks of sponge, which were kept moist with a solution of com-
mon salt. When we desired to introduce the strychnia into the system we
moistened the sponge attached to the negative pole, and sometimes both, with a
solution of this substance. That the strychnia may readily be conveyed into
the system by this means is shown by the experiments of M. Fabre-Palaprat
(see this Journal for February, 1834, p. 561), but also by the fact that usually
much greater twitchings of the muscles were observed when the solution of this
substance was employed, than when the sponge was wet merely with the solution
of common salt. When the whole force of the battery was not wanted, instead
of placing the slips in the extreme cells, they were placed in cells more or less
remote, according to the power required ; thus the force was easily regulated.

" We are persuaded that properly employed, galvanism is a valuable and effec-
tive remedy for certain forms of amaurosis.

We tried electro-magnetism, in several cases in the hospital during our service
in 1839, and also in private practice in a number of cases, but we are not sensi-
ble of its having been productive of the slightest benefit in a single instance.
From this it would appear that, for remedial purposes, a regular and constant
galvanic current is more useful than the violent shocks produced by interrupted
currents, as induced by the electro-magnetic apparatus. A DanieU's battery
would probably therefore be the best apparatus."

As regards the effects of disease of the peri-orbital region, alluded to in
the preliminary remarks of this paper, it has been noticed that cancerous
and other ulcerations have been followed by amaurosis, whether dependent
on reflex disease excited within the eye, or reflex irritatioyi, as in some of
the cases of cicatrices and tumours referred to, could not have been deter-
mined without the aid of the ophthalmoscope.^ In some of the cases

' The good effect of the free application of tinct. iodine to the forehead iu photo-
phobia is probably not so much due to mere counter-irritation as to a stimulating
effect on the filaments of the supra-orbital nerves.

80 Lente, Amaurosis and other Disorders of the Eye. [July

recorded or referred to in this paper the injury has evidently been too
trivial, that is, too little violence has been inflicted to produce concussion
of the eyeball or brain ; we can then only look to inflammation developed
within the eye, and consequent effusion between its coats, or to reflex irri-
tation, as the cause of defective vision. We consider that we are justified
in referring to irritation as the cause, when we have, as in Case I, and in
Dr. Yan Zandt's case, improvement of vision following immediately upon
the removal of the foreign body; but the ophthalmoscope has now furnished
us with more positive evidence. In Dr. Noyes' case, the patient was a
physician ; a blow on the orbit, apparently not injuring the eye at the
time, was followed by total blindness, and by partial anassthesia of the parts
supplied by the supra-orbital nerves. Subsequently the normal sensation
returned, but the vision did not. A thorough ophthalmoscopic examina-
tion by Dr. Noyes revealed perfect integrity of every portion of the internal
structure of the eye. In his concluding remarks. Dr. Noyes says, "The
loss of sight was the direct result of the blow, it was immediate, it was
total. No cause appears to explain it save injury to ^the supra-orbital
nerve ; yet, how to connect these facts understandingly is certainly very
difficult." It may be, indeed it has been repeatedly objected to the theory
of reflex irritation accounting for this phenomenon, that we see a great
variety of wounds and cicatrices in various situations around the orbit, and
yet seldom see any disturbance of vision in connection with them. "It is
well known," says Mackenzie, " that every wound of the branches of the fifth
pair does not produce amaurosis." This is undoubtedly so. Since my
attention has been specially directed to this subject, I have noticed numbers
of instances of well-marked cicatrices about the orbit not attended by im-
pairment of vision. We know equally well that an immense majority of
punctured and contused wounds of the hands and feet are not followed by
tetanus ; yet, occasionally a very trivial injury of these parts is followed
by tetanus and death, and the wound is none the less regarded as the cause
of the tetanus, because it fails to succeed so many similar injuries. We also
are aware that hundreds of stumps, after amputation, heal without subse-
quent trouble ; but that, nevertheless, nerves are sometimes so implicated
in the cicatrix as to give rise to such intolerable neuralgia of the stump as
to necessitate reamputation.

There are several features in the rather remarkable history of Antoinette
H. which require some notice before concluding this article. It was ob-
jected by a very distinguished oculist, to whom the case was related soon
after its occurrence, that the wound, being on the left side, the amaurotic
symptoms should have affected the left eye, and not the right. But, this
is not more remarkable than that disease in one tooth should occasion a
violent toothache in another perfectly sound; or that irritation of the nerves
of the stomach by acidity should induce violent neuralgia of the supra-orbital
nerve; or that an irritating application to the mucous surface of the eyelid

1862.] Lente, Amaurosis and other Disorders of the Eye. 81

should determine also an immediate irritation of the Schneiderian membrane,
succeeded by violent sneezing; or that simply touching the memhrana tym-
2Mni with a probe should sometimes give immediate relief to a toothache.
We see, moreover, that in other cases, the same phenomenon has been ob-
served as in one of Dr. Wallace's cases. We notice, also, that pressure
on the wound caused pain, not in the left but in the right eye, which was
also aggravated during the steps of the operation, and materially mitigated
after its completion. Perhaps the most striking feature of the case was
the immediate though not complete relief of the amaurosis by the abstrac-
tion of the foreign body. She instantly exclaimed, "Now I can see with
it," though suffering from the smarting of the wound. This fact, taken
in connection with the subsequent history of the case, the frequent subsi-
dence of the symptoms, and their sudden return, w^ithout any obvious cause;
the violent train of neuralgic symptoms which ensued, the extension of the
''numbness" to the left side of the face, and the coincident affection of the
left eye; the rapid and simultaneous subsidence of both symptoms, together
with the occurrence, months afterwards, of visvs dimidiatus, is worthy of
particular notice.* I would also call attention to the periodical character
which the symptoms for a time assumed ; the exacerbations occurring on
alternate nights, and finally yielding to quinia; likewise to the violence of
the neuralgic symptoms, simulating at one time tetanus, in the rigidity of
the muscles of the jaws, the spasms of those of the back of the neck, and
their aggravation by attempts to flex the head on the chest, thus developing
a quasi opisthotonos. Such phenomena are not unparalleled in such inju-
ries. Camerarius relates a case where a slight wound near the outer can-
thus of the eye was followed by alarming, symptoms, among which was
temporary hemiplegia. And various writers, as Desse, Morgagni, Petit,
record cases in which the most severe symptoms, in one or two instances
resulting in death, followed apparently trifling injury about the orbit. As
regards the intermittent complications, the following case, which can only
be alluded to in general terms, is apropos. A very distinguished politician,
who is just now attracting considerable attention, became affected, a few
years ago, with violent ophthalmia of one eye; the suffering was severe,
and the symptoms increased notwithstanding the most assiduous medical
attention, resulting in ulceration of the cornea, and even threatening the
life of the patient. At this time, a physician at the south, who had for-
merly treated the patient, hearing of his critical condition, wrote to his
medical attendant to try quinine in full doses: this was done, and very soon
an improvement was manifest; the inflammatory symptoms subsided, and
the patient recovered, but of course with the loss of vision, and some de-
formity of one eye. As bearing on this case, I quote the following para-

' It is worthy of note that an older sister of the patient has total amaurosis of
one eye, which resulted from a fall on the head.
No. LXXXYIL— July 1862. 6

Ash HURST, Burns.

[July

graph from Todd and Bowman's Physiological Anatomy : "The study of
the pathological conditions of this nerve illustrates its physiology in a
highly interesting manner. Frequently the branches of this nerve, in
greater or less number on one or both sides, may, according to the humoral
view, form a focus of attraction for a morbific matter generated in the
blood, in persons exposed to the paludal poison, or in persons of rheumatic
or gouty constitution ; in these cases, as in most others of similar pathology,
the neuralgia occurs in paroxysms of greater or less severity, each paroxysm
being followed by a period of convalescence, which lasts, it may be sup-
posed, until the morbid matter has been again accumulated in sufficient
quantity to induce a high degree of irritation of the nerves."

In my case no miasmatic development has previously been noticed, nor
had she been exposed to paludal poison.

Cold Spring, April 18, 1862.

Art. y. — On Burns. By John Ashhurst, Jr., M. D., late Senior
Resident Surgeon to the Pennsylvania Hospital.

The occurrence in our city, at an interval of only six months, of two
such terrible accidents as those of the Continental Theatre, in last Septem-
ber, and of Jackson's cartridge factory, in March, has drawn attention in
the profession more strongly than for a long time before to the treatment
of burns, avowedly the w^orst class of cases in surgery.

As from my official connection on both of those sad occasions with the
Pennsylvania Hospital, in which institution a large number of the sufferers
were received, my experience in these accidents has been larger than falls to
the lot of many surgeons, I have thought it might not be uninteresting to
make some short remarks upon the nature of such injuries, and the mode
of treatment which has in the hospital been found most efficient.

No cases demand more urgently immediate and judicious treatment than
burns, and yet perhaps in no cases are more ignorance and incompetence
shown by too large a number of medical men. I shall not attempt system-
atically to discuss the pathology and symptoms of burns, but shall glance
rapidly at the indications and modes of treatment.

And first, the burn is to be looked upon as a constitutional more than a
local affection. The first question should be, does the sufferer feel cold ;
and his pulse and respiration should be carefully observed. Put the patient
instantly to bed and cover him with as many blankets as can be obtained ;
give him quickly a moderate amount of stimulus and a decided anodyne,
such as sixty drops of laudanum with an ounce of brandy. The first danger

1862.]

AsHHURST, Burns.

is from shock : of ten patients received into the PennsylYania Hospital last
September from the fire at the Continental Theatre, six died within twenty-
four hours and from shock ; some having never reacted, and some after
partial reaction sinking again with frightful rapidity. And when this
secondary shock comes on, the patient will, as far as my experience goes,
certainly die.

Do not be in a hurry to dress your patients before attending to their
constitutional treatment ; remember that they will perish from shock if
reaction be not obtained, and that they will bear the necessary exposure of
having their wounds dressed much better after reaction, than while in the
shivering almost collapsed state in which you will probably find them when
first called.

Brandy and opium are the remedies most to be relied on in the treatment
of burns. Brandy should be given in the form of milk-punch in preference
to being mixed merely with water, as furnishing digestible food at the same
time with the stimulus, and being less likely to intoxicate than when given
in the native state. If you should be so unfortunate as to make your
patient drunk, or as is very apt to be the case if your patient is drunk when
brought to you, promote reaction as much as possible by external stimula-
tion and use only the more diffusible stimulants internally, especially the
preparations of ammonia. Carbonate of ammonia in doses of five grains,
made into an emulsion with gum and sugar, may be advantageously given
as often as every half hour, and is probably the best of the ammoniacal
preparations. In an emergency the aromatic spirit of ammonia* in doses
of half a teaspoonful, or even the common hartshorn mixed with sweetened
water may be used. The amount of stimulation which is well borne and
even necessary in these cases is surprising. For weeks and weeks I have
given patients two ounces of milk-punch containing one-third brandy, every
hour day and night, making a pint of brandy in the twenty-four hours, and
this to delicate women and perfectly sober men. Large doses of opium are
also required. I generally give as much as half a grain of the sulphate of
morphia every six hours. Almost every one of the twenty-two cases which
came into my wards on the twenty-ninth of March, had a tablespoonful of
the officinal Liq. morpli. sulpliat.,''^ or thirty minims of laudanum, at
intervals of six hours, for many days ; and this was no more than enough
to quiet the nervous jactitation and restlessness which is one of the most
distressing syn»ptoms of burns.

When the surgeon has seen to the general condition of his burnt patients,
and not before, he may properly inquire as to the extent of their injuries.
And upon this must in a great degree his prognosis be formed.

If half of the surface be involved, no matter how superficial the bum
may be, or how good may be the patient's condition, he will almost surely
die. Even a burn of one-third of the surface, if it be over the trunk, will
almost necessarily prove fatal. And in no case should a recovery be cer-

AsHHURST, Burns.

[July

taiiily predicted, for burns are not only the most mortal, but the most
deceptive injuries the surgeon is called upon to treat.

Only a small portion of the surface is to be dressed at once, and it is
well to have some systematic mode of procedure. I usually dress the arms
(for they are almost always involved) before any other part, then proceed
to the body, and dress the face last : this is important, as the dressings
cannot be applied as closely to the face as to other parts, and are apt to
fall off and require renewal during the changes of position necessary for
securing the dressings to the chest or back.

The material generally used at the hospital as a primary dressing is the
"carron oil," consisting of linseed oil and lime water. This is the most
convenient application; its results are I believe as good as can be obtained
from any other, and in my practice it has been found far more soothing
than anything else I have made use of.

The zinc paint is a good dressing, but requires to be frequently renewed,
as it becomes dry, and is then very irritating. It is made by incorporating
the oxide of zinc with linseed oil, and is applied by means of a brush.
Kentish's ointment I have used, but do not see any advantage it possesses
over the carron oil, while it is not nearly so comforting to the patient, and
is more difficult to be procured when the emergency suddenly arises.

I have also painted burns with the solution of lunar caustic, as recom-
mended by Mr. Skey, but have not observed that the sensibility of the parts
so treated was diminished by the application.

I therd*ore decidedly recommend the ''carron oil" as the best dressing
with which I am acquainted. If linseed oil cannot be obtained, good lard
oil will answer nearly as well : the oil forms a bland, soothing, not easily
evaporating coating to the sores, while the lime water is unirritating, and
3'et furnishes just enough stimulation to save what can be saved and hasten
the removal of parts already dead.

The best method of applying the oil is to soak pieces, not more than
eight inches square, of patent lint, Canton flannel, or even old linen or
cotton goods, in the mixture, and having laid the dressing thus prepared
on the parts to be covered, to apply accurately over the whole oiled silk :
this prevents evaporation, and at the same time secures much greater clean-
liness than can be obtained in any other way.

Should the burn be of the first degree, or even of the second, provided
the vesication were not very extensive, I should suppose, lOn theoretical
grounds, carded cotton might be a good application, as recommended by
several surgeons, among others, by Dr. Anderson, ^ by Prof. Cooper,^ and
by Mr. Newnham and Dr. Black. ^

Even in these cases I should be disposed to cover the parts thoroughly

' 'Glasgow Medical .Journal, for May, 1828.

2 Medical Times, December 11, 1847.

3 Provincial Medical and Surgical Journal, February 9, 1848.

1862.]

AsHHURST, Burns.

with the carron oil before applying the cotton. Where, however, the parts
are more deeply involved, rendering suppuration inevitable, I should very
much prefer the dressing by means of patent lint and oiled silk.

Although I have not myself used cotton, I am familiar with its applica-
tion in the hands of others, and I have not observed from its use the great
relief from suffering which Dr. Anderson considers one of its principal
advantages. If cotton be used it should be carefully prepared ; as met
with in commerce it is too apt to contain germs which heat and moisture
will develop into maggots, than the discovery of which in a sore I can
imagine nothing more loathsome to the surgeon.

The dressings should be retained in place by means of roller bandages,
which are more satisfactory in every respect than sticking plaster.

The face should be covered with a mask prepared in the same way, and
having holes cut for the mouth and eyes. It is better to keep the cloth
over the face wet by frequent reapplication of the oil ; but if this cannot be
done it may be covered with oiled silk, secured in this case by adhesive
plaster, for a bandage around the head is unnecessarily confining.

When the patient is dressed he almost always expresses himself as feeling
much more comfortable. He should be encouraged to make hearty meals.
Soup, soft-boiled eggs, light meats, such as chicken, are especially adapted
to these cases. The bowels are very often constipated at first, and should
be opened by mild enemata: in the course of a few weeks, however, exhaust-
ing diarrhoea is apt to set in, and must be controlled by injections of lauda-
num or black drop. Retention very often, and sometimes suppression of
urine occurs during the first days. This is particularly to be watched for
in women, who from modesty are often prevented from making their wants
known.

The most universal accompaniment of burns and scalds is extreme thirst,
and from an injudicious gratification of this desire (in obedience, perhaps,
to the vulgar impression that water will put out the fire supposed to be
lurking in the system) arises one of the most unfavourable symptoms, viz.,
sickness of stomach. I am in the habit of allowing small pieces of ice
to be held in the mouth, or may give small quantities of carbonic acid
water ; but on no consideration permit more than a mouthful of water to
be drunk at once.

When the patient has been comfortably dressed and has sufficiently re-
acted, he may be considered out of immediate danger if the extent of surface
burnt is not too great. The third and the eleventh are often spoken of as
being critical days, and certainly death is very apt to take place about these
periods from hypostatic congestions and effusions upon lungs or brain, from
tetanus or other unavoidable complication. After reaction, if the patient
eats and sleeps well, is quiet, and does not vomit everything he swallows,
he may be considered as in a very favourable condition. If, on the other
hand, he become violently delirious, tossing off" the bedclothes, and even

AsHHURST, Burns.

[July

tearing the dressings from his own sores, instantly rejecting whatever he
eats or drinks ; and thus, while taking no nourishment, exhausting himself
in every way, his chances of life are very much diminished.

The delirium of burns more closely resembles that of mania-a-potu than
anything else. It is in fact delirium tremens, the trembling delirium, with
the same cold clammy sweat, running pulse, incessant motion of the hands
and feet, glaring eye, strange and frightful delusions, whispering voice,
piercing shrieks, persisting wakefulness, and too often sudden death, which
are so sadly characteristic of the drinking mania.

And the treatment is the same : brandy, opium, lupulin, valerian, and
the whole category of nerve stimulants ; upon these we are to rely as our
only means of saving life.

The local treatment in this the second stage of burns must depend on
the condition of the surface. And it is most important that the sores
should be dressed as seldom as possible. 'Now this is not lazy surgery, but
the contrary is meddlesome practice. I have known men calling themselves
surgeons dress their unfortunate patients three times in one day, and claim
credit for their zeal. This is all wrong ; the first dressing should not be
disturbed till absolutely saturated with the discharges ; after this the harm
of exposure entailed by a redressing will be less than that caused by the
presence of so offensive a mass as the old dressing has become.

I have generally found it necessary thus to renew the dressing after two
days, and thenceforward every other day it will be usually proper to dress
our patients entirely anew. I would reprehend the practice of dressing
half a patient's sores one day, and half the next ; this leaves them always
dirty, and yet always exhausted by the fatigue of being dressed. As soon
as the slough has come away from any part, I remove the carron oil or
whatever dressing has been applied at first, and make use of simple cerate
spread upon patent lint. For this may subsequently be substituted the
carbonate of zinc cerate, or the unguentum zinci oxidi, according to the
nature of the granulations.

In washing burns, after removing the soiled dressings, and previous to
applying the clean, great care must be exercised.

The water should be at least at the temperature of the room ; better
warmer than colder ; the room itself should be warm. I always, before
dressing a burnt case, shut all the windows and doors and open the register.
Care should be taken not to touch the raw surfaces with the sponge used
in washing ; the granulations are very sensitive and bleed easily. On the
other hand, the new skin surrounding the sore should be carefully wiped
free from all the discharge which accumulates upon it ; for it is important
for the patient's health that this skin should exercise as fully as possible its
exhalant powers. For the same reason, in applying the dressings no more
than the part really sore should be covered, for to cover the new-formed
skin renders it useless.

1862.]

AsHHURST, Burns.

When granulation and cicatrization have begun, it is advantageous at
each dressing to stimulate the sores by gently squeezing from a sponge a
little whiskey over the healing surface. This is very painful, but if the
dressing be instantly applied the suffering is only momentary. In the latter
stages of burns of the fourth degree and deeper, the sore presents the
appearance of an ordinary healthy ulcer ; here touching the edges with
lunar caustic in substance is very useful in promoting cicatrization. Of
course in this the third stage of burns care must be taken, by the use of
suitable splints and bandages, to obviate the unsightly contractions which
are apt to follow burns affecting more than the mere surface.

The constitutional treatment during the third stage must be the same as
would be proper during any extensive suppuration, from whatever cause.
I cannot agree with Kentish in recommending low diet and purgatives
during this stage of burns. The best food the patient can get, stimulus
graduated according to his condition and the extent of surface suppurating,
and the administration of tonics, I think give a much better chance of
recovery than the opposite treatment. I generally give ten drops of the
niuriated tincture of iron with one or two grains of the sulphate of quinia
or of cinchonia three times a day, the alkaloid being converted into a soluble
preparation by the addition of sulphuric acid. If exhausting night-sweats
supervene, I have found advantage in the use of the elixir of vitriol, or the
nitro-muriatic acid. Opium throughout is a very valuable remedy, though
less required in the later than in the early stages.

The various complications which arise in the treatment of burns and
scalds must be met secundum artem. Coma, which sometimes occurs in
the early stage, of course forbids the use of opium. Tetanus, which coming
on in these cases is very apt to be fatal, may be treated with the Cannabis
Indica. This remedy I have given with success, in the dose of one grain
of the extract every two hours.

Burns are the opprobrium of surgery, and will always continue to be so,
under whatever treatment; but I firmly believe the mortality might be much
diminished, could the rules which have been impressed upon my mind by
sad experience be made equally clear to every practitioner.

I. "We must look first to the general condition of our patient, and only
secondarily to the local mischief done; and while many topical applications
answer equally well, we must look upon the constitutional treatment as all
important. Many a poor girl's life has been lost by not having been given
enough to eat, and by brandy and opium being withheld, and the stomach
deluged with floods of cold water instead.

II. A burn is essentially a disease of depression, not of excitement.
Even the violent delirium is but simulative of excitation, and the remedies
here again are food, brandy, and opium.

III. There is nothing to be eliminated ; no "fire to be drawn out." All

88 Packard, Treatment of Fractures of the Femur. [July

that we have to do is to strengthen nature inwardly, protect her from the
assaults of cold air and other enemies without, keep the functions regular,
and meet complications as they arise.

IV. Although we know that a large proportion of our cases will cer-
tainly die, we must not give up any one till absolutely in articulo moriis.
But we should never give a positively favourable prognosis iu any case,
however slight it may appear, until at least the first and second stages have
passed by.

Y. In no cases is decision more called for than in these : the patient may
die while the vacillating surgeon is making up his mind what to do. Act,
and act quickly; should our patients recover, their gratitude and thankful-
ness will amply repay us for our trouble and anxiety; should they die, the v
consciousness that we have done all that human skill could do, will prevent
our making that, to the physician, most dreadful reflection, that to our own
ignorance or neglect have the lives of our patients been sacrificed.

Philadelphia, April, 1862.

Art. YI. — On the Employment of India-rubber in obtaining Continuous
Extension in the Treatment of Fractures of the Femur. By John H.
Packard, M. D., of Philadelphia. (With a wood-cut.)

So many contrivances for the treatment of fractures of the femur are
already before the profession, that it would almost seem as if every possible
expedient, every imaginable form of apparatus, had been resorted to. And
yet the results obtained are not satisfactory, nearly all surgical writers
confessing that an inconvenient degree of shortening of the limb almost
invariably ensues. The reason assigned for the occurrence of this sequela,
in cases where there is no loss of bony substance, is the contraction of the
muscles, which cannot be, or, at least, is not, overcome.

Whole pages might be covered with quotations to prove that this is the
great difficulty in treating fractures of the femur. Mr. Syme, of Edinburgh,
is, I believe, the only eminent surgeon of the present day who considers
extension to be useless in such cases, and his results, as published,^ are too
favourable to be implicitly received as true.

Now when we glance at the vast array of screws, bands, buckles, and
other devices for "keeping up extension," it becomes interesting to ascer-
tain why it is that the end is not after all answered. In most cases, if the
surgeon is called at once, he can restore the limb to its normal length by

' Observations in Clinical Surgery. By James Syme, Professor of Clinical Sur-
gery in the University of Edinburgh. 1861.

1862.1 T^j.r. KARD, Treatment of Fractures of the Femur.

pulling upo\d cr ether being administered if the muscles are very powerful,
or are spasmcaically contracted. And immediate reduction is probably
performed by the great majority of surgeons, notwithstanding the statement
of some authors that no change takes [)lace at the seat of fracture for eight
or ten days. It would certainly be strange if the muscles, left to themselves,
did not shorten, so as to produce, maintain, or increase overlapping of the
fragments.

But if the force applied to keep the limb at its normal length were suf-
ficient, and the apparatus did not yield to the tonic or spasmodic action of
the muscles, it is plain that shortening could not occur. Whether such an
absolutely unyielding tension could be borne by the patient, or whether the
necessary pressure would not be too much for the skin, we need not now
inquire. As soon, however, as the apparatus stretches in any part to any
degree, in just that degree is the extension done away with.

In view of these difficulties, I would call the attention of surgeons to the
value of India-rubber as a means of making steady and uniutermitting trac-
tion, such as is needed in the treatment of fractures of the thigh. My own
use of it has been limited to one case, which I will presently detail. Let
me first, however, cheerfully acknowledge my indebtedness for the idea to
Mr. Barwell, who describes and represents, in his late work on " Diseases
of the Joints," an elastic "accumulator" used by him in the treatment of
hip-disease.^

John E., aet, 18, was playing with some other boys, when he in some
way struck his right thigh against the shaft of a wagon, with such force
as to break the bone at about the junction of the middle and lower thirds,
I saw him an hour or two after the accident, which took place on Sunday
afternoon. There was no difiBeulty in defining the injury, at a glance, from
the deformity, helplessness, and shortening of the limb. His temperament,
naturally irritable, had been rendered more so by an injudicious bringing
up ; he was therefore impatient of pain or restraint, and almost any treat-
ment was likely to prove irksome to him.

. Placing him in bed, I laid the limb on a pillow, and fastened his shoul-
ders to the upper cross-piece of the bed-frame by means of a towel folded
cravat-wise and passed under his back, the ends coming up in front, counter-
extension being thus made from the axillae. Extension was made by ap-
plying adhesive plaster in the usual way, and then hanging to the bight of
the band a couple of flat-irons, weighing together about ten pounds.

No other mechanical treatment was employed for several days, the limb
remaining comfortable and in proper position. Meanwhile I had a pair of
splints made like those of Desault as modified by Physick, except in the
arrangement for extension.

^ I am aware tliat Dr. Gurdon Buck, of New York, in describing his mode of
treatment by means of a suspended weight (xim. Med. Times, March 30, 1861),
suggests the use of an India-rubber band passing over the pulley, so as to combine
elasticity with the extension ; but, with all deference to that able surceon, I can-
not see how any advantage is gained, if the weight is properly regulated, by such
an arrangement.

Packard, Treatment of Fractures of the Femur.

[July

On the inner side of the long outer splint, at its lower herremity, was
fastened a solid block of wood, 2|- inches in thickness eacn way, and as
wide as the splint at that part. The middle portion of the block was now
sawed out, with the corresponding part of the splint, so as to leave a space
for a pulley, the axis of which ran through the middle of each lateral part
of the block. This pulley, 2 J inches in diameter, was thus so placed that
the extending band would play in its grooye.

I had procured, at an India-rubber store, a day or two previously, a
''chest-expander," consisting of a round cord of gum-elastic, a little more
than half an inch in diameter and about fifteen inches in length, having at
either end a handle placed transversely. From
this I had had the handles removed, substituting
at one end a square, flat piece of wood to be
received into the bight of the extending band of
adhesive plaster, while at the other end was
placed a ring, to which was sewed a small flap
of leather. These arrangements will be readily
understood by reference to the annexed cut.

Applying the apparatus in the usual way, I
brought the India-rubber cord into the groove
of the pulley, and drawing upon it until it was,
in my judgment, tense enough, I tacked the
leather flap to the outer side of the long splint.
The boy made no complaint of the severity of the
traction upon his limb, although it was if any-
thing greater than that usually made with inex-
tensible bands. From this time forth the mus-
cles were steadily drawn upon, night and day,
by the contractile force of the India-rubber; and
when he at last got out of bed, he could not,
standing on his left foot, perceive any difference
between the two limbs in regard to their length.
He has now (April 2d) been walking about, first
on crutches and then with a cane, for more than
eight weeks, and has not the slightest perceptible
limp. Accurate measurement is impossible, the
muscularity and plumpness of the boy's figure
masking the bony points of his pelvis : but as
far as the degree of shortening can be estimated,
it is a scant half-inch.

The above method, although it seemed to me
to answer the end perfectly in the case detailed,
might doubtless be improved upon. For instance,
it has been suggested to me to substitute a strap
passing through a buckle for the leather flap
tacked on to the outer side of the long splint.
Perhaps it would be as well to let the extending band itself play over the
pulley, the India-rubber cord being stretched along the outside of the splint.
Another way would be to let the India-rubber cord terminate in a ring at
either end (a plain, double loop would answer, if of sufficient strength), the

1862.] Christian, Epidemic Relationsbip of Zymotic Diseases. 91

extending and counter-extending bands being tied, the former to the lower,
and the latter to the upper ring.

Whatever plan is used, the surgeon must remember that continuous
stretching weakens the gum-elastic. It is better to have a very thick and
strong band or cord than a thin one, as in the former case the force can be
equally well-regulated, and is far less apt to be weakened by time. The
pulley is absolutely essential, unless the extension is direct, which would
require a splint of inordinate length. Two or three inches of the India-
rubber cord should be free between the adhesive plaster and the pulley, in
order to make the elastic force operative.

Besides the usual mode of making counter-extension by the stuffed fillet
in the perineum, commonly known as the perineal band, other plans, as is
well known, have been proposed. Dr. David Gilbert, of this city, recom-
mends the use of adhesive plaster, applied around the upper part of the
thigh. Dr. Hartshorne has invented an apparatus in which a block fast-
ened between the two splints is fitted to receive and bear against the tuber
ischii. Other plans have from time to time been brought forward for fixing
the upper part of the apparatus against various points in the bony pelvis.
I^ow, the chief difficulty in regard to counter-extension is that of avoiding
excoriation from pressure. But, as a matter of course, the elastic element
in one portion of the chain would give spring to all the rest, so that any
pressure would be made more tolerable. On the other hand, in case of
stretching of the adhesive strips, or any other material used for counter-
extension, the India-rubber cord should be made so tense as still to maintain
its traction on the muscles.

It is probably unnecessary to go into any argument to prove that the
weight suspended to the foot acts on the same principle of continuous ex-
tension ; and, therefore, that this plan may be resorted to when the other
is for any reason inconvenient or out of the question. A pulley for the
cord to run over is an important advantage, although not essential, when
the weight is used.

Art. VII. — On the Epidemic Relationship of Zymotic Diseases.
By E. P. Christian, A. M., M. D., Wyandotte, Mich.

Observation seems to have determined conclusively that there exists a
certain relationship, or consanguinity, using the word as correctly as in its
popular acceptation, between some diseases of an epidemic character. As
it regards erysipelas, and a form of puerperal metritis, this relationship
seems to amount to a pathological identity ; and less determinately, but

92 Christian, Epidemic Relationship of Zymotic Diseases. [July

with more than plausibility, may arguments be adduced iu favour of the
same conclusion respecting other epidemic diseases.

Inquiries iu relation to the pathology of epidemics, tend greatly towards
proving the fact of the unity of zymotic diseases in their origin, or epidemic
cause; observation, therefore, becomes not so exclusively directed towards
establishing their differential diagnosis, as to studying the generic points
of those possessing, apparently, less of family similitude.

Not only has similarity of pathological manifestations challenged obser-
vation in some of these diseases, scarlatina and erysipelas, for instance, but
so does especially their epidemic relationship, in the uniformity of their
sequence and concurrence.

It has been often observed that certain epidemics either prevail together,
or follow each other with such uniformity and regularity, that the convic-
tion of its being the result of something more than mere accident is irre-
sistible; that there are indeed definite laws governing these phenomena,
and it is more than probable that these laws, when known, will point out
to us, not the pathological identity of these diseases, but an identity of
epidemic cause : the difference of resulting pathological phenomena, consti-
tuting the specific disease, being determined by other intrinsic or extrinsic
circumstances.

In confirmation of this statement, I cite the common concurrence of
erysipelas and puerperal fever ; of scarlet fever and measles ; of erysipelas
and scarlet fever ; the latter with typhoid fever also, and probably with
diphtheria too : all as modified forms of the action of the same zymotic
poison, or modified zymosis from the same epidemic cause.

Opinions not sustained by facts are of little weight, and we confess to
having been impressed, chiefly, by common observation, without having
made any large collection of facts bearing on the subject ; still we adduce
the historical concurrence and succession of epidemic diseases iu this viciniiy,
during the past six months, as confirmatory of this law, so far as it goes,
believing that accurate observation will continue to adduce similar evidence.

In August or Septeml)er of the past year, rubeola appeared in this and
neighbouring villages, prevailing epidemically, as it did also near other
large sections of country. The general presence in the atmosphere of the
zymotic cause was strongly indicated in this neighbourhood by the number
of those attacked. Very few of the unprotected population escaped ; yet
it operated with comparatively little virulence, as out of an aggregate of
more than one hundred and twenty cases, not one death occurred that could
be fairly charged to this disease ; the only two cases in which it so termi-
nated, were both children previously afflicted with chronic ailments, which
became so much aggravated as to result in death.

Before Christmas, measles, in an epidemic form, may be said to have
subsided, more probably from want of subjects on which to act, than from
a subsidence of the epidemic cause, it being never entirely absent from the

1862.] Christian, Epidemic Relatioiisliip of Zymotic Diseases. 93

village until March, sporadic cases occurring occasionally, in concurrence
with other diseases, which we are about to mention.

In December, while the measles was at its height, I was called in attend-
ance on cases of unequivocal and severe diphtheria, in the neighbour-
ing village of Ecorse, distant two miles from Wyandotte ; this disease
prevailed also, in a virulent form, and quite as extensively. In its outbreak
it invariably attacked those who were just convalescent from measles. Not
a single case of scarlatina had occurred in the village up to this time, though
there were some subsequently, before its entire disappearance.

Just at this time, while in attendance on diphtheria at Ecorse, a virulent

anginose affection occurred in Lizzie C , a child of seven years, in this

village, who was just convalescing from measles, and the case bearing every
resemblance to those I was attending at Ecorse was pronounced the same.
There was not the slightest appearance of an eruption, nor any desquama-
tion of the surface, a fact I mention, because in some which occurred subse-
quently, where there was no appreciable eruption, desquamation took place
during recovery. During the convalescence of Lizzie, a younger sister, also
just recovered from measles, sickened, and in three days died, with all the
symptoms of unequivocal scarlatina anginosa. Several other children in
the same family sickened with well-marked scarlatina, and recovered.

From this family, scarlet fever, of an intense anginose and malignant,
variety, spread rapidly into those of friends and neighbours, and gradually
over a large part of the village, until, by April, an aggregate of more than
eighty cases came under observation, with ten deaths, all occurring among
very young children. The disease, in its onset, continued to attack those
lately recovered from measles, and at first, also, electing those for its victims
who had in any way been exposed to contagion from the sick, but eventu-
ally seizing upon some who had been most carefully and vigilantly guarded
from it, and, on the other hand, strangely passing by those who had been
repeatedly exposed.

All through the progress of this epidemic, there were cases of diphtheria
occurring occasionally, of a character well marked, and very distinct from
the anginose affection of scarlatina, until about the middle of March, this
disease may be said to have reached the character of an epidemic also. It
prevailed chiefly among adults, or those of fifteen years and upwards, but
not exclusively so; the scarlatina as generally selecting children, though
sometimes seizing upon adults. In families where the scarlatina prevailed
among the children, the adults were especially liable to an anginose affec-
tion, varying in intensity in individual cases. The diphtheria attacked
those who had had scarlatina in infancy. None passed through the two
forms of the disease. The former prevailed most amongst those who had
not been exposed to scarlatina, and was as likely to seize upon a single
member of a family as upon several, the reverse being the case with scarla-
tina.

94 Christian, Epidemic Relationship of Zymotic Diseases. [July

And ijovv I will briefly detail the peculiarities of some individual cases,
exhibiting another zymotic element present as an exciting cause, or else
showing still other modifications of zymotic disease from the epidemic con-
stitution of the atmosphere.

The following case is cited as a type of many which occurred during the
scarlatinal epidemic : —

About the first of February, the babe of Mr. Dewitt, aged four months,
sickened with scarlet fever, three older children in the same family just con-
valescing from the same disease, which they had had severely. In the babe,
the enlargement of the submaxillary glands was very great, though not so
large as in two of the older children who recovered. It was of an erysipe-
latous appearance, and instead of the general efflorescence on the surface,
there were discrete patches of erysipelatous swellings scattered principally
over the limbs. This child died on the second or third day, from the
intensity of the blood poison, and not apparently from any local compli-
cation.

Tebruray 16th, I was called to see M. Drunnan, aged twelve. The street
on which he lived had been the hot-bed of scarlet fever, over twenty children
having had it in a severe form, within a space of three hundred yards. This
boy had never had the scarlet fever, but had recently recovered from measles.
I found him with high continued fever ; great general disturbance of the
organic functions ; and erysipelas extending from the ankles over a large
part of both legs. He recovered by resolution in about ten days. Other
children of the family subsequently sickened with genuine scarlet fever.

About the same time I attended Mr. Eva, who had simply run a small
splinter into his finger, from which erysipelatous inflammation extended
half way up his forearm, and sloughing of a large part of the cellular tissue
of his finger took place.

M. Twaddle fell, and struck the back of his hand, not violently, yet ery-
sipelas set in, and sloughing of much of the cellular tissue ensued.

.Other cases of a similar nature occurred, not necessary to detail.

In the convalescents from severe attacks of scarlet fever, furuncles and
abscesses were common, not merely about the glands of the neck, but in
the chest, back, and abdomen. All such cases recovered without any sub-
sequent relapse, as did also those generally in whom the eruption took the
form of minute vesicles, covering the scarlet efflorescence like sudamina.
These were successful efforts on the part of nature to eliminate the morbific
matter or poison from the system.

In proof of the coexistence of still another allied form of disease, I will
now detail the two following cases : —

March 3d, Mrs. A. was confined with her fourth child. March 8th, Mrs.
II. was prematurely delivered of her first, at the eighth month of ntero-
gestation. In the latter case there was ample cause for all subsequent
developments, from the fact of premature labour having been induced by a
fall, and laborious exertion in stowing away a load of hay. The labour was
exceedingly severe and tedious, owing to the narrowness of the pelvis; and
none biit the services of an ignorant midwife were sought until the last
stages of labour. The night after the birth of the child she arose from the

1862.] Christian, Epidemic Relationship of Zymotic Diseases. 95

bed on the cold floor to administer to the wants of her babe, being unable
to arouse her attendant. The next morning I found her with intense metro-
peritonitis. She was bled, with entire relief of pain, and reduction of the
pulse. In the evening there was increase of soreness again. Leeches were
applied, and afforded relief; again the disease lighted up with increased in-
tensity; again bleeding was resorted to ; but the patient subsequently died.

On the day of this woman's death, acute metritis lighted up in the first
named patient, Mrs. A., being the twelfth of her own confinement. At the
same time erysipelas of the integuments about the left eye set in. Leeches
were applied, and copious flowing from the bites encouraged for several
hours on the lower part of the abdomen, with entire relief of the metritis,
and also of the erysipelas.

It is proper to say now, however, that among a number of other partu-
rients about the same time, and some of them under unfavourable circum-
stances, there was nothing to interfere with their normal recovery.

Now, then, the inquiry suggests itself, is such a concurrence of zymotic
diseases, which is not at all uncommon, satisfactorily explained by the
theory of one prevailing epidemic leaving its impress on all concurrent
diseases, or the epidemic constitution of the atmosphere modifying and
impressing the prevalent diseases ; or does it not rather indicate a close
family relationship, or consanguinity between these zymoses, originating
perhaps from the same epidemic cause, and the specific characters of each
disease being derived from other, and as yet unknown causes ?

In conclusion, if the marked pathological dissimilarity in these associated
diseases is advanced as an argument against the identity of their cause, or
more correctly, against an intimate causal relationship, we may cite on the
other hand the marked difference of pathological manifestations arising in
different individuals, placed under similar circumstances, exposed to the
same morbific cause, paludal malaria ; the different resulting diseases de-
pending upon a variety of modifying circumstances. In those exposed to
the action of this malaria, we may observe the protean forms of miasmatic
disorders, as numerous, and more varied than those above enumerated. We
see intermitting, remitting, and continued fevers ; neuralgias, intermittent
and continued, in a single, or a set of nerves, and other phases of nervous
derangement innumerable; dysenteries, diarrhoeas, and bilious colics ; Jaun-
dice; pneumonias, and even cutaneous eruptions, &c. &c. l^ow is it less
rational to suppose there may be a similar unity of origin of those asso-
ciated epidemic diseases, than of these endemic disorders whose cause, if
more appreciable, is certainly quite as intangible.

96 Johnston, Description of a Pseudencepbalic Monster. [July

Art. YIII. — Description of a Pseudencepholic Monster. (Genus 11,
Thlipseucephalus, Isidore G-eoff. St. Hilaire.) By Christopher John-
ston, M. D., Baltimore. (With three wood-cuts.)

I AM indebted to ray friend, Dr. J. Dwinelle, of Baltimore, for the
privilege of making the following observations upon a living Thlipseu-
cephalic monster, and also a dissection of the abnormal parts.

A lady in her sixth confinement gave birth to a large, living, male child,
robust and well-formed in its other parts, but monstrous in the development

of its head, which, strongly

plantar surface; its weight 8^ pounds on the second day of its existence.
The testicles had not descended.

It may not be amiss to remark that the mother, an exceedingly amiable
person, was peevish and irritable during her entire pregnancy, which she
claims to have exceeded the normal period by one month ; and that, at
about the third month, she received a severe internal injury from a child
who leaped with force upon her abdomen.

The foetus presented normally, and the labour, although somewhat
tedious, was not severe. As soon as born, the child moved its limbs and
trunk ; its respiration was at once established, and it uttered cries which
were remarked to be more feeble than those of ordinary children. But,
although the circulatory and respiratory functions soon became active, the
countenance remained livid, while yet the rest of the cutaneous surface
assumed a fresh rosy tint.

The ready movements of the mouth attracting attention, the mother was
besought to apply her offspring to the breast ; l)ut nothing could overcome
her repugnance to nursing "so hideous a monster," whereupon, the nurse
essayed -successfully to feed the child with sugar and water administered
with a spoon.

The birth occurred on the 19th of July, at 11 o'clock A. M., and I first
saw it on the 20th, at 6 P. M., in the interval between which hours urine

Fig. 1.

bent backwards, was deficient
in both bone and natural in-
tegument above a line pass-
ing over the orbital plates of
the frontal, the petrous por-
tion of the temporal, and
along the lateral sinuses of
the occipital bones. The
shallow cranial cavity was
occupied by a flat scarlet
tumour, 2J inches in length
by in breadth, varying
from J to I of an inch in
thickness, and which was
lobulated so as to suggest
the idea of hemispheres and
cerebellum. Fig. 1.

The length of the child
was 19 J- inches, the umbilicus
beins" at 10 inches from the

1862.] Johnston, Description of a Pseudencephalic Monster.

and meconium had each been voided once. The radial pulsations could
not now be counted, but the heart's rhythm was regular and even, and its
beatings numbered 160 in the minute. Respiration, 44 per minute; in-
spiration at times suspirious, but generally sobbing; expiration slightly
hoarse, yet effected in a single effort. The thoracic and abdominal respira-
tory movements were full, although somewhat laboured. Temperature of
the body cool ; that of the face conspicuously so.

The child moved its limbs, and grasped what it touched with the hands.
It obeyed the calls of nature, partially closed the eyelids, which presently
relapsed into their former half-opened state, but it appeared to be, and
doubtless was, unconscious ; and the ocular globes, which diverged a
little in strabismus, as well as the pupils, remained immovable even when a
lighted candle was brought into close proximity to them.

When undisturbed the little creature now made no effort to alter its
position ; it shrank, however, if flies crawled over its head, and started
almost upright whenever the tumour, especially the posterior part of it,
was touched. Yet it is worthy of remark that pressure exerted upon the
same part was productive of very inconsiderable effects, although, at the
moment of contact of the finger, sensibility seemed painfully heightened.

At the period of my visit mentioned above, the child was reported to
have lost much of its energy, but it could still practise suction upon a finger
introduced into its mouth, and it swallowed a bland fluid which I adminis-
tered in a spoon ; notwithstanding the attendants were unwilling to satisfy
the wants of so forbidding a creature. It continued to grow feebler and less
livid until about one o'clock A. M. of the 22d (62 hours), when the respi-
ratory act was arrested and renewed several times, and it stretched out its
limbs and presently expired.

Appearance of the body nine liours post mortem. — Face livid ; tumour
had subsided somewhat, and was of a less brilliant color ; the rest of the
body was of a yellowish hue.

Head. — A careful dissection revealed the following, viz : The three red
lobular masses, upon being opened, were found to consist entirely of spongy
vascular substance surrounding a considerable number of cysts or loculi
containing a dark amber-coloured fluid. Upon removing the remaining
portion of the occipital bone, namely, the part below the inner protuberance,
and which was entire, laying bare the atlas and dentata, the arches of
which were deficient, and cutting away the arches of the other cervical
vertebrae, the dura mater was found to be much thickened, and to present
the appearance of a network including a serous fluid in its meshes. The
medulla oblongata being exposed, the pia mater surrounding it was of a
deep-red colour and thickened, and was lost in the tough substance of the
tumour. Indeed, like the dura mater just noticed, the pia mater, in this
situation as well as in the tumour, which was evidently an abnormal de-
velopment of this expansion, offered all the characters of an erectile tissue.

The medulla spinalis was perfectly normal, as was also the medulla ob-
longata, which terminated the nervous tract anteriorly. There were no
hemispheres nor trace of nervous matter in the red lobes, but in the quasi
cerebellar lobule a little node or mass as big as a pea was found in a cyst.
The pons was absent ; but upon the upper extremity of the medulla, poste-
riorly lay a little roundish mass of nerve-substance of a dark purplish -red
colour, measuring y\ of an inch in diameter.

Two semi-fibrous cords passed separately, one from either side of the
base of the red tumour, through the ontic foramina of the sphenoid, and
No. LXXXYIL—JuLY 1862. ' 7

98 Johnston, Description of a Pseudencephalic Monster. [July

represented the optic nerves. But while there was no sug:gestion of a chi-
asma or of nerve-matter in the cords behind the sella turcica, it is espe-
cially worthy of note that in front of the posterior clinoid processes the
cords each contained a little bundle of nervous filaments, which were con-
tinued into the orbits. These nerve-fibres were carefully studied with the
aid of the microscope, and they corresponded in all particulars to those
taken from the optic nerves of a stillborn but perfectly formed child.

The first nerve was wanting ; the second has just been mentioned ; the
third and fourth were also absent ; the fifth nerve arose out of the outer
corner of the extremity of the medulla, which was very red at this point.
The Gasserian ganglion and the underlying motor bundle were distinctly
recognized, and the three branches of the fifth traced to their foramina of
exit. Figs. 2 and 3.

The sixth was perfect in course and appearance, and seemed to be com-
posed of two filaments in one sheath.

The remaining six nerves, and also the cervical spinal nerves, were nor-
mal, except that the hypoglossal had a very low apparent origin.

The pituitary ''gland," or, rather, a reddish body representing it, occu-
pied the sella turcica.

No farther dissection was allowed.

In reviewing the above statements the reader will at once perceive that
the strabismus depended upon' the existence of but a single motor nerve in
the orbit ; for when, animated by the sixth nerve, the external rectus had
once contracted, the globe remained everted on account of the total absence
of antagonistic power to restore equilibrium.

With regard to the movements executed by the infant, it must be ad-
mitted that they were purely reflex and involuntary, for although all the
sensitive nerves of the body and head were in normal condition (if we ex-
cept the absent relation of the fifth nerve to the tuber annulare), the entire
cerebrum and pons varolii were wanting, and of the cerebellum there re-
mained only a diminutive rudimentary button fastened down upon the pos-
terior surface of the medulla, which might exert a pronominal co-ordinating
influence upon muscular motion. It is true that irritation of any sort
applied to the tumour, particularly the posterior surface, which was some-
what chafed as it was thrown back against the pillow, occasioned au

Fig. 2.

Fig. 3.

Medu'la oblongata ; Anterior view ;
Natural size.

Medulla oblongata ; Posterior view ;
Natitral size.

1S62.]

Kerr, Hospital at Canton.

immediate start ; but we must discriminate betwixt this convulsive effort,
in which the loill could not possibly be involved, and the " endeavour by
voluntary movements to escape from a painful irritation, which, as an
evidence of sensitiveness to external impressions, is still possible when, after
ablation of all other parts of the brain, the tuber annulare and medulla
oblongata are respected." In the present instance, Nature had paused at a
condition in the human subject which art has striven to reach in lower
animals ; and that, too, without those embarrassing side consequences with
which scientific mutilations are too frequently attended.

Art. IX. — Cases treated at the 3Iedical 3Iissionary Societi/s Hospital
at Canton, China. By John G. Kerr, M. D. (Communicated by Prof.
S. D. Gross, M. D.)

Of the surgical cases presented for treatment at the hospital in Canton,
the most important are those requiring operations for the removal of stone
in the bladder. There are no statistics to show how common this affection is ;
but that it is of frequent occurrence may be inferred from the fact that not less
than fifty cases are seen annually at the two missionary hospitals in this city.

It is unnecessary to enter into a discussion of the causes which produce
calculous diseases; but it may be remarked, as bearing on the subject,
that, as tea is the universal beverage of the Chinese, they do not drink
water until it has been boiled, and the lime which it contained is thereby
precipitated to a greater or less extent. It is a very rare thing for a China-
man, even of the poorest classes, to drink cold water. In this country,
therefore, the disease cannot be attributed to the use of water impregnated
with the salts of lime.

It is a remarkable fact that urinary calculus has not been met with in any
other part of China than Canton Province. Dr. Lockhart, of Shanghai,
and Dr. McCartee, of Ningpo, who have practised among the Chinese for
about twenty years, have informed me that they have never met with a case.
Tliat the disease exists in other parts of this vast empire is not unlikely,
but it remains for future observers to discover the localities.

The first operation for stone in the bladder was performed in July, 1844,
by the Rev. P. Parker, M.D., who was the founder of the Medical Missionary
Society's Hospital. Up to the end of 1851 Dr. Parker had operated on
30 cases, only two of which were fatal. He had, I think, half a dozen other
operations which have not been published. In 1854-56 Dr. W. G. Dick-
son operated on nine cases at the Medical Missionary Society's hospital.
One case was fatal. About 39 cases have been operated on at the Hospital
of the London Missionary Society in this city, of which nine have died.
The operators were three English surgeons and one Chinese surgeon edu-
cated in Edinburgh.

100

Kerr, Hospital at Canton.

[July

Remarks.

Lithotrity.
11th day.

Opium sraolvcr,

2d day.
Lithotrity,

Opium smoker.
Two stones.

Encysted.

Two stones.

Result.

o o o

o--i2o.^^.. -ZZ o

C P^ C P5

Weight.

W O !M O (r<l O O M oV"i'0 O CI rH O r-n'r-t !— HOOr-HOOO

. Diameters.

I— 1 S^CJr-iCqr--rq — r-r-^SSlr— It— i (7^1— ((Ml— C^i— 4C^rOl— Ir—I

Chemistry.

Uric acid

Phos. lime
Uric acid
Oxalic
Uric acid

Phos. lime

Uric acid

Triple phos.

Phos. lime
Uric acid

Date of Operation.

May 23, 1856
Oct. 10, "
Oct. 17, "
Nov. 29, 1859
Dec. 2, "
April 10, 1860
July 5, "
July 5,
July 27,
Aug. 11, "
Sept. 18, "
Nov. 15, "
Dec. 4, "
Dec. 11, "
Dec. 11, "
April 8, 1861
April 8, "
May 17. "
Aug. 12, "
Sept. 9,
Sept. 9, "
Sept. 30, "
Oct. 30,
Oct. 30, "
Nov. 4, "
Nov. 13,
Dec. 30, "

Duration.

CO . , • . M .

P -.It- C >^
1— i ^ rH —i 1—1

Occupation.

I^abourer
Farmer

Shopkeeper

Shopkeeper
Carpenter

Labourer

Shopkeeper
Tile-maker

Paper dealer

Farmer

Wire-maker

Boatman

Farmer

Small trader

Farmer

Shopkeeper

('arpenter

Farmer

Small trader

Sanshwui
Kauming

Canton

Tungkwan

Nanhai

Canton

Pwanyii

Szhwui

Shauhing

Tungkwan

Sinhwui

I'wanyli

Szhwui

Sinhwui

rieungshan

Fuhshan

Tungkwan

Pwanyii

Tsingun

Pwanyu

Nanhai

Szhwui

Tungkwan

Sanhing

Pwanyii

o GO to o c~ c- c-i — J iQ — 1 X' 1— d r— cc ^ C5 ^ r-H o ^ L— 1— 1 '

No.

1862.]

Kerr, Hospital at Canton.

101

The above tabular statement includes all the operations for stone
performed by myself up to the end of 1861. It will be noticed that no
cases occurred in 1857-58. This was owing to the fact that the operations
of the hospital were interrupted during those years by the war betw^een
England and China.

A few remarks on some of the cases is all that it is necessary to add to
the facts contained in the tabular statement. The majority of the patients
reside at distances of less than fifty miles from Canton. A few lived far-
ther away, and one or two resided at a distance of about one hundred miles
from the capital of the province.

The lateral operation has been performed in all the cases, except two, in
which lithotrity was employed. This operation would be resorted to more
frequently in suitable cases, but that patients are not willing to stay the
length of time necessary for its completion. The stone in Case No. 23
would have been crushed but for an error in measuring it, although this
•jvas carefully done before operating. The case was an excellent one for
crushing, but the recovery of the patient after being cut was slow and un-
satisfactory.

In Case No. 3, the stone was covered with a deposit of crystals, which
made its surface very rough. The bladder was no doubt extensively dis-
eased, as the foreign substance had been in the viscus for so many years.
There was a large deposit of muco-purulent matter in the urine. Reaction
did not take place after the operation, and the patient gradually sank from
irritative fever of a typhoid character.

In Case No. 10, the operation was followed by an abscess in the left
internal iliac region, the matter from which was discharged at the incision.
He lingered for several weeks with but little prospect of recovery, and
finally returned to his home, about ninety miles distant. About six months
afterward he returned to the hospital, very much improved in health, the
abscess having entirely healed, but he still had symptoms of stone. After
vseveral careful examinations, a small stone was found in the membranous
portion of the urethra, which had formed, no doubt, during his long illness.
He declined submitting to any attempt to remove it, and left the hospital.
In the beginning of the present year he was met with again at the dispen-
sary in Fuhshan, in the enjoyment of robust health. The small stone had
))een discharged some months before, and was followed by entire relief of
all his sufferings. This man complained of inability to discharge semen,
although erections took place as usual.

Cases No. 1 and No. 20 were opium smokers. The appearance of the
latter was like that of a man in the decline of life at 60, although his age
was only 47. When he first came to the hospital the operation was declined
on account of his general debility, and the indications of extensive disease
of the bladder. He returned to the country, and, after spending some
months in a place more salubrious than his own residence, he came back to

102

Kerr, Hospital at Canton.

[July

the hospital, with a decided improvement in his general health. The ope-
ration was undertaken with reluctance, but finally his urgent requests were
yielded to. The stone had three rough places on its surface which were
the cause of much irritation of the raucous membrane. One of these rough
places was so situated as to be in the form of a jagged hook, and in the
extraction was the cause of much laceration of the tissues. Notwithstand-
ing all these unfavourable circumstances, the patient recovered slowly and
left the hospital about a month after the operation.

In Cases 'No. 24 and No. 25 the stones were unusually rough, and had
caused chronic inflammation of the bladder, which made the cases very
unfavourable. The stone in No. 24 was encysted, or so grasped by the
thickened and contracted coats of the bladder that it was almost impossible
to extract it, and, after nearly two hours' bard work, I was on the point of
giving it up, when, at last perseverance was rewarded with success. The
size and roughness of the stone, in Case No. 25, rendered its' extraction
very difficult, and about one hour and a half were consumed before its
removal was effected. In both these cases, great violence was done to the
tissues of the perineum, both by bruising and lacerating, and this, added
to the chronic disease of the bladder, rendered the recovery of the patients
exceedingly doubtful. They both, however, recovered gradually, but slowly,
without any serious drawback. When they left the hospital, they were stili
suffering from chronic disease of the bladder, but there was every prospect
that removal to the country would soon result in perfect restoration of
health.

The last case. No. 27, was complicated with stone in the urethra, which
had caused inflammation and swelling of the penis with ulceration of the
glans. This stone was about one inch long, by three or four lines in diameter
at one end, tapering to half that size at the other end. After its removal
the penis was restored to a healthy state by fomentations, laxatives and
other means, and then it was found there was urinary calculus. On per-
forming the lateral operation, two stones, of the same shape and size, were
removed, and the patient made a favourable recovery.

No case of calculus in the female has been met with.

With reference to the treatment after the operation, it may be stated that
the patient is placed on boards with a thin straw mat — the common Chinese
bed — and that these boards are separated three or four inches so as to allow
the urine and feces to be received into a vessel below. No dressing was
applied to the wound, but frequent bathing with tepid water was practised.
Each patient had his own attendant, and but little control could be exer-
cised over the diet. When able to buy it they often took medicine from
native physicians.

In one case only was there dangerous hemorrhage, and this happened on
the fourth or fifth day, in a patient 50 years old.

1862.]

FouRGEAUD, Puerperal Uraemia.

103

Art. X. — Case of Puey-peral Ureemia. Bv Y. J. Fourgeaud, M. D., of
San Francisco, California.

Called upon to attend Mrs. , on the 24th of September, 1861, I

was informed that she had had several miscarriages, and that her two living
children were born before the eighth month. I found her face oederaatous,
and she complained of loss of sight, so that it was difficult for her to dis-
tinguish persons at a few feet from her, and was unable to read printed
matter.

Suspecting from these symptoms that she was under the influence of
uraemic intoxication, I requested that her urine should be sent to me for
examination. Having submitted it to the usual test, by fire and acid, the
result confirmed my fears. An albuminous deposit of more than one-third
of the quantity of urine submitted to the test settled the diagnosis.

Having informed her friends of the danger of her situation, I placed her
immediately under the prophylactic treatment of Braun, hoping thus to
avoid the imminent peril attending such cases, and especially convulsions.

On the 27th, I lost all hope for the life of the foetus, its movements
having ceased, and auscultation revealing no foetal pulsations. Having
again auscultated her on the following day, with no better result, I felt
satisfied that the fostus was dead, and so informed her friends.

She was taken with labour-pains on the 1st of October. At that time,
although the quantity of albumen in the urine had considerably diminished,
the amblyopia had gradually increased to such a degree that she could not
distinguish common objects near at hand.

I placed her under a moderate influence of chloroform, whenever the
pains would come on, and, after a few hours, she was delivered of a seven
months' foetus, which, to all appearance, had been dead for three or four
days. Her labour was otherwise natural, and passed off without convul-
sions— a circumstance which I attribute altogether to the prophylactic
treatment and the use of chloroform.

The following morning, finding that she had not passed water, I relieved
her with the catheter. I was then informed that she could not move her
legs, and, upon examination, I found her paraplegic. The muscles of the
upper half of the body were altogether intact and performed their function
naturally. The pulse was rather feeble and excitable. The brain was in
a normal condition, the intellect perfect, deglutition and articulation good.
The spine gave no indication of pain until coming to the third lumbar
vertebra, where pressure was intolerable, there being much tenderness from
that point to the extremity of the coccyx — the pain being greater, however,
on the lumbar vertebras. The motor power of both legs was entirely lost,
sensibility being but partially impaired. Paralysis of the rectum and
sphincters, with involuntary discharges of feces ; paralysis of the bladder,
with retention of urine ; amaurosis, the eyesight being almost entirely gone.
Such was the condition of the patient on the 2d of October.

On the 3d there was suppression of the lochias (which did not return
again), fever and great tenderness and swelling over the abdomen, which
continuing for several days, caused me to fear a metro-peritonitis. How-
ever, all the inflammatory symptoms and pain gradually subsided under
treatment. (Abdomen covered with large linseed meal and poppy poul-
tices; clysters of the same nature. Diet: milk, tea, and dry toast.)

104

FouRGEAUD, Puerperal Uraemia.

On the 6tb, no change in the paralytic symptoms. The urine exhibited
a large quantity of mucus, with earthy phosphates, alkaline, highly ammo-
niacal and so thick and ropy that micturition was often difficult and some-
times quite impossible through the catheter, until the instrument had been
cleansed of the secretions which clogged it. Specific gravity of urine 1012.
The catheter was used three or four times a day, and the bladder was
washed out daily by freely injecting tepid water into it. The spine and
lower extremities were rubbed with lin. ammonise, and afterwards with the
following: R. Tinct. nucis vomicae Jj ; Liq. ammoniae 5ij ; M. pro lin.
The infusion serpentari^, with the addition of quinine, was ordered three
times daily; also: R. Acid, benzoic, ^iss; Dec. pareirae 5xvj ; Morph.
acet. gr. ij. M. A tablespoonful three times a day, with five drops of
vin. colch. rad. Patient objecting to blister on the spine, stimulating
liniments were used. A slight running from the bowels having supervened,
it was checked by starch injections with a few drops of laudanum.

18th. No important change in the amaurotic and paralytic symptoms.
Electricity was used on this day for the first time, and continued for several
days along the spine and legs and over the region of the bladder. The
urine was free from deposits and mucus ; colour, pale amber, no trace of
albumen; reaction, alkaline; sp. gr. 1011.

20th. Sight improved a little, begins to distinguish persons in the room ;
can move left leg. Bowels are somewhat better under her control, but no
improvement in the paralysis of the bladder. The retention of urine per-
sisting, the catheter has to be used. Right leg still completely paralyzed
and oedematous from knee to foot. Bandaged it up. Sp. gr. of urine
1012. Colour, pale amber; reaction, acid. No trace of albumen.

Nov. 1st. Her general health continues to improve. Right leg still
paralyzed and oedematous. Troublesome cough. Continue treatment ;
also : R. Syr. scill^, Syr, acacias aa Jj ; Tinct. opii camph., Tinct. vale-
rianse aa 3iv. M. Take two teaspooufuls in a little water pro re nata.

22d Since the first the patient has continued to improve gradually, but
steadily. Her eyesight Tias made such progress that she can now read
print. The oedema has disappeared, and the paralysis of the leg is con-
siderably diminished. She can now take a few steps, being supported.
Yesterday she passed water for the first time since her confinement, without
the aid of a catheter. Urine, clear, amber colour; sp. gr. lOlT ; no albu-
men. Her bowels are under her control, and it is only occasionally that
she has an involuntary passage of feces. The tenderness over the spine is
now very slight. Continue treatment. One of the following pills daily :
R. Strychniae gr. j ; Cons, rosag q s. M. Ut fiaut pil. xii.

2Qth. All the paralytic symptoms much better. Can walk across the
room without support. Urine, natural; sp. gr. 1018. Has to use the
catheter only occasionally.

The patient continued to improve until the month of December, when
the family being about to remove to their country residence, I recommended
gentle exercise, the use of sea-water baths, good nourishing diet, with port
wine and brandy, and Pil. ferri carb. gr. x daily.

With the exception of an occasional relaxation of the sphincters, under
fatigue, when she over-exerts herself in walking, the patient has entirely
recovered.

1862 j

105

TRANSACTIONS OF SOCIETIES.

Art. X[. — Summary of the Proceedings of the Pathological Society of

Philadelphia.

1862. Jan. 22. Singular Lesion of the Urinary Bladder. — Di\
Packard exhibited the right lung and the bhidder of a man, set. 25, who
died in the Christian Street Military Hospital, of pleuro-pneumonia follow-
ing measles.

An immense effusion of turbid serum, full of flakes and shreds of yellow
lymph, distended the right pleura and compressed the lung. The two layers
of the pleura adhered to one another by means of soft yellow lymph over
a space about as large as the palm of the hand, at the side. Spots of con-
gestion, amounting almost to extravasation, were scattered here and there
through the lung tissue. The mucous membrane of the trachea and bronchi
was deeply reddened, and the bronchial glands much swollen. Nothing
abnormal was noticed in the left lung.

All the cavities of the heart were distended with black blood, partly fluid,
and partly in soft cnrrant-jelly like clots ; on cutting into the ventricles the
mass was squeezed up into the incision. Within the pericardium there was
a small quantity of turbid serum, but no inflammation of the membrane
could be detected.

The liver was rather large and fatty, the spleen soft and pale. The pan-
creas was so soft as to be easily torn, but was rather injected than otherwise.
The kidneys were pale.

On laying open the urinary bladder, which was contracted into a very
small space, there were noticed on its floor several elevations, of various
.shapes, one crest-like, another broad and flattened, but all presenting aii
intensely red colour as if inflamed, and one or two looking as if ulcerated.
The rest of the mucous membrane was perfectly smooth and pale, but a
large portion of the surface of the urethra was deeply congested.

Feb. 12. Dr. Packard exhibited a urinary bladder presenting a curious
analogy to that in the foregoing case, from a man who died of pneumonia
supervening upon measles, in the Christian Street Military Hospital.

The right lung was intensely congested throughout, carnified and break-
ing down easily under the finger or by tearing, at the lower part. Its
pleura was universally adherent. The bronchial glands were greatly en-
larged. Left lung healthy.

The heart was norm.al, containing rather more than the usual amount of
firm white clot.

The liver was large and slightly fatty; the spleen quite soft.

The kidneys were congested ; the supra-renal capsules normal.

The urinary bladder was very small. Being laid open, its mucous mem-

106

Proceedixgs of the

[July

brane was found pale and smooth, except at two points, posterior to the
orifices of the ureters, where there existed deep-red, smooth patches, looking
like bloodclots. One of these patches was more prominent than the other ;
the mucous membrane was entire over both of them.

Feb. 26. Compound Comminuted Fracture of the Skull, and Fracture
of Bibs. — Dr. Ashhurst presented these specimens, with the following
history : —

John S. P. was admitted into the Pennsylvania Hospital, Feb. IT, 1862,
about 10.30 A. M., on account of an obscure injury received the night pre-
vious. There were two wounds over the left temple ; one anterior and
smaller, penetrating to the bone, but not connected with any fracture ; the
other, about an inch and a quarter long, communicating directly with a
fracture through both tables of the skull. There was an opening in the
bone, oval in form, with some fragments lying loose in the wound, which
were removed by the attending surgeon. An escape of brain substance and
cerebro-spinal fluid constantly took place from the wound: there was no
bleeding from the ear, but a piece of lint saturated with blood was found ia
the pinna, as if bleeding had occurred previous to the patient's entrance into
the hospital. The patient's mind appeared confused, but active ; there was
an almost complete loss of language. There was very great dyspnoea, and
a careful examination revealed a fracture of several ribs on the left side.

The removal of the loose fragments of bone from the skull was followed
by some bleeding, which was not, however, so profuse as to be alarming.

Towards night the patient became worse, and the next morning he pre-
sented the rather startling symptoms of a pulse of 120 and respiration of
44 to the minute. Being kept, however, at perfect rest, on absolute diet,
and with cold applications to the head, with the usual dressing for fractured
ribs, he improved, and for several days seemed to be in a favourable condi-
tion. On the morning of the 25th, however, there was a decided change
for the worse : internal strabismus, at first of the right eye, and afterwards
of both; dropping of the mouth on the right side; rapid and anxious
breathing, and a running pulse, all betokened danger : while the hands,
which lay outside of the bed-coverings, were cold, the skin of the body was
pungently hot, a thermometer placed in the right axilla indicating a tem-
perature of 106° Fahr.

Death, preceded by profound coma, occurred about 1 P. M. of the 26th.
An autopsy was made three and a half hours after death, with these
results : —

Thorax. — Fractures of the third, fourth, fifth, sixth, and seventh ribs on
left side; extensive old pleuritic adhesions on right side. • One small apo-
plectic clot on outer edge of left lung. Pneumonia of lower part of right
lung posteriorly. Ossific deposits on pericardium, and in the heart tissue.

Head. — Valvular wound in left temporal region, and oval opening in
skull ; several small pieces of bone imbedded in the dura mater and brain :
the opening in the skull was about three-quarters by half an inch in dimen-
sions. There was a clot on either side of the longitudinal sinus.

The upper surface of the brain, for two inches on either side of the longi-
tudinal sinus, was covered with lymph ; there was much congestion and
extravasation under the arachnoid. The tissue of the brain was firm, except
around and behind the wound, where it was much softened. The wound
ran through the left anterior lobe of the lirain to the summit of the left
hemLsphere, and a large clot filled the cavity.

1862.] Pathological Society of Philadelphia. 107

In this case death resulted from pressure dependent on hemorrhage, which
must have been gradual, from the slow approach of the fatal symptoms.

The medico-legal bearings of this case are of interest. In my examina-
tion before the coroner's jury I gave the opinion that the injury resulted
from a fall rather than from a blow, because the fracture in the skull was
above the wound of the soft parts, not below it ; and I thought most pro-
bably an upward blow would have glanced and have produced no fracture.
This view was confirmed by the facts elicited.

Gangrene of the Lung. — Dr. Leet exhibited a specimen of this lesion,
the history of which was as follows : —

Henry B., aged 49, coloured, was admitted February 16, 1862, into the
Philadelphia Hospital, in charge of Dr. Da Costa. He stated that he had
been sick for two weeks ; but, owing to his evident stupor, his statements
about himself were not considered reliable. He affirmed that before the
onset of the acute attack from which he was suffering, he had had a cough
from time to time, for the last few years. This was corroborated by the
nurse, who remembered him in the house, in 1860, with a cough, which
improved much under treatment. His condition on admission was one of
extreme prostration ; his breathing very rapid; his pulse quick and feeble;
his skin hot, and covered with perspiration. His face wore an anxious
look, and he was evidently not fully conscious. He had spells of coughing,
after which he expectorated with some difficulty a quantity of dark sputum,
which in parts was of an olive appearance. Like his breath, it was ex-
tremely offensive. His weakness was so great that it was with much diffi-
culty he was propped up in bed long enough to permit of the chest being
examined. The physical signs detected were marked dulness on percussion
at the upper portion of the chest, anteriorly and posteriorly on the left side,
and indistinct blowing respiration, not in the least tubular, and entirely
unlike that met with in pneumonia. Moist rales could also be heard over
both lungs. From a consideration of all the circumstances of the case, a
diagnosis of gangrene of the lung was made. The patient remained until
the morning of his death much in the same condition as when first seen,
not responding in the least to the stimulants that were freely administered.
He became more and more stupid, but still not delirious. For several hours
before his death the breathing was extremely difficult and very rapid,
although unattended with pain ; indeed, at no period while under observa-
tion did he complain of pain, although he always stated when questioned
that he suffered from a dull feeling of oppression. He died on the 21th.

At the autopsy a mass of blood, in part clotted, and about a pint in
quantity, was found in the left pleural cavity. The whole of the upper and
middle portion of the lung was disorganized, presenting a soft, dirty, and
broken down appearance, shading off' where the lung became more solid,
first to a greenish, and then to a grayish hue. The odour from the de-
stroyed lung was highly offensive, and like that of the breath during life.
The pleura in the neighbourhood of the disorganized lung tissue had been
destroyed. The right lung did not show any signs of disease worthy of
notice. The heart was to the eye healthy.

March 12. Mammary Carcinoma. — Dr. Ashhurst exhibited a can-
cerous breast removed by Dr. Pancoast from a patient in the Pennsylvania
Hospital.

This patient is a woman forty years of age, who, although married, has

108

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[July

never borne cliildren. Her general health is good, except that she suffers
from haemorrhoids.

She first noticed this tumour, which was seated in the lower portion of
the right breast, more than a year ago. It has never given her any pain,
but during the last few months has increased rapidly in size. She attributes
this to her having used her arm constantly during this time in sewing.

The operation was performed under ether. Several of the axillary glands
being enlarged, were removed. The microscope revealed cancer-cells in the
tumour itself, but not in the accompanying glands. Since the operation
this patient's condition has been as favourable as could be desired.

Rupture of the Urethra. — Dr. Lee exhibited a specimen of this injury,
and related the history of the case.

John H., £et. 11, was admitted to the Pennsylvania Hospital March 1,
1862, with rupture of the urethra and extensive extravasation of urine.
His mother said that, six months before, he had fallen astride a fence and
injured his perineum ; he then suffered from retention, but, after some diffi-
culty, a surgeon passed a catheter, which was retained for several days.
When this was removed, he could pass a small stream, but his urine soon
began to dribble, and has continued to do so ever since. In this state he
remained until the day before his admission into the hospital, when the flow
of water ceased altogether; his desire to urinate became urgent, and just
before going to bed he strained violently to pass water but could not suc-
ceed. In the night, the lower part of the abdomen was swollen and tender;
he called his mother's attention to it, but she thought nothing of it until the
next morning, when she found the hypogastrium of a dull purple hue, and
the penis and scrotum very oedematous and of nearly the same colour.
About mid-day, she took him to the Jefferson College clinic, where one of
the clerks recognized his dangerous condition and sent him at once to the
hospital. When admitted (about 3 o'clock P. M.), he was in a state of
extreme collapse ; skin cold, and no pulse perceptible at the wrist. The
scrotum and penis were enormously distended, the former of a dark-brown
hue; across the hypogastrium and left iliac region there ran a track of
gangrene three inches broad, of a livid colour, with here and there black
puffy spots which crepitated under pressure; it was intensely painful to the
touch, and the little patient tried to relieve the terrible distension by flexing
the thighs on the body.

Efforts were at once made by my colleague, Dr. Ashhurst, and myself, to
introduce a catheter, but without success on account of a tight stricture,
apparently in the membranous portion of the urethra. I then made free
incisions in the penis, scrotum, and gangrenous portion of the hypogas-
trium, from which fluid with a strong urinous odour freely exuded; no in-
cisions were made in the perineum, as I wished to leave this region free for
the operation of perineal section, which, had the little patient rallied, would
have been his only resource. After the incisions were made, yeast poultices
were applied, and free stimulation constituted the rest of the treatment. At
first the patient rallied slightly from his collapsed condition, but he speedily
sank again, and died about 5 o'clock the following morning.

At the autopsy, the urinous infiltration was found to extend as high as
the umbilicus, and laterally as far as the crests of the ilia ; thence it de-
scended to tlie penis and scrotum, which, as already stated, were enormously
distended. Upon opening the abdomen no urine was found in the pelvis,

1862.] Pathological Society of Philadelphia.

1C9

nor was there any perceptible peritonitis ; it was evident, therefore, that no
rupture existed posterior to the triangular ligament.

The bladder and the whole of the urethra were removed together, when
the former was found much thickened and hypertrophied by chronic inflam-
mation, and its mucous membrane was streaked with clotted blood. The
urethra was healthy in the prostatic and membranous portions, but at the
bottom of the spongy portion a tight impermeable stricture was found, and
just behind this a gangrenous rent which was plainly the seat of rupture.
Th'e urine had thus escaped first (as usual in such cases) into the perineum,
and thence, prevented from reaching the pelvis by the deep perineal fascia,
it had travelled upwards along the groin into the connective tissue of the
hypogastrium. Both kidneys were enlarged and sacculated, and the pelvis
of the left was distended to a marked degree ; that of the right kidney,
although dilated, was much less so than that of the left. Both ureters
were also much dilated, but here- the dilatation was chiefly on the right
side.

The extravasation of urine had been going on for thirty-six hours, for
it had evidently begun on the occasion of the straining efl'orts at micturi-
tion made on the evening before entering the hospital.

The case was manifestly one of chronic retention with incontinence of
urine, and, had it not been neglected through the ignorance of the parents,
could probably have been saved by the same treatment timely applied.

Dr. Harris remarked that he had searched in vain, in the journals to
which he had access, for a case similar to this in the gradual formation of
the stricture. Usually, extravasation of urine took place at once.

Gunshot Wound of Femur and Pubis. — Dr. Packard read the follow-
ing account of a post-mortem examination made by him in a case of this
kind, in a young man, set. 20, wounded at Bull Bun, and subsequently im-
prisoned for several months in Richmond, Ya. : —

Autopsy ten hours after death. — Wound only examined. Body excessively
emaciated; legs and feet oedematous. Yery little, if any, rigor mortis.

The orifice of entrance of the ball, completely cicatrized, was observed
near the upper edge of the left trochanter major. The opening by which
it had been removed, in the fold between the perineum and left thigh, about
opposite the posterior boundary of the scrotum, gave exit to bloody, ill-
conditioned pus, whenever pressure was made upon the surrounding parts.
From this latter opening there led olf several sinuses, lined with black
sloughy matter.

On dividing the integuments towards the back of the thigh on a director,
and thus laying open one of these sinuses, the trochanter minor, detached,
was found, as well as the inner wall of the upper end of the shaft, burst
out, as it were, into several fragments. The shaft of the femur seemed
swollen and rough ; but a closer examination showed that this was a shell
of new bone, inclosing the necrosed upper two-thirds of the true shaft. At
one part of the anterior face of this shell was an irregular opening, about
an inch wide by an inch and a half long, closed by a blackish, sloughy, but
tough fibrous expansion. Perhaps an explanation of the necrosis may be
found in the fact that several small splinters of bone had been driven down
along the medullary canal, and may have wounded the nutritious artery.
A clot occupied the canal, very dark-red and tough above, paler and softer
below. In the upper part of the cavity of the shell of new bone, there
existed several necrosed and decomposing fragments.

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[July

The hip-joint, when laid open, was found to contain some turbid reddish
synovia, and the foveola of the acetabulum was reddened and evidently un-
sound. None of the surrounding abscesses, however, had formed any con-
nection with the joint.

The ball seemed to have struck the ischium between the tuberosity and
the spine, and to have passed up along the ramus nearly to the crest of the
pubis, gouging away the anterior or outer wall of the medullary cavity of
the rami.

A sloughy sinus or abscess extended down the inner side of the thigh as
far as the knee, and others were traced up under Poupart's ligament as far
as the origin of the psoag muscles.

If, as was stated, this injury was inflicted by a Minie ball (and hardly
any other would have produced such havoc), the course taken by the pro-
jectile was different from that which has been observed in most other cases.
The ball would seem to have entered over the trochanter major, passed
backwards and inwards, through the broad cancellous upper extremity of
the shaft of the femur ; after breaking through the inner wall of the latter,
it passed across to the border of the pelvis, and ploughed its vi^ay upward
till its force was spent. For a round ball to have thus rolled irregularly
about would have been no very strange matter ; but we have been given to
understand that the Minie ball forced its way without deviation.

Another point is well illustrated by this case, namely, that longitudinal
splitting seldom, if ever, crosses the line of junction of an epiphysis. Here
the shattering of the bone was very severe, and yet above the line just
referred to, there was not even a fissure — a fact which accords with the ex-
perience of Stromeyer and Macleod.

3Iarch 26. Deformity of Legs. — Dr. Lee exhibited the bones of a leg
amputated for deformity, and a cast of the limb before removal, with the
following history of the case : —

Sanford A., aet. 19, from Ohio, was admitted to the Pennsylvania Hos-
pital March 13, 1862. From infancy, he had suffered from fragilitas ossium,
and the lower limbs had been repeatedly fractured; his right leg alone had
been broken ten or twelve times. After these accidents the bones would
very rapidly unite, so that in two or three weeks he was able to go out
again. That firm union was gained so soon could not be established, be-
cause he never walked upright, but always upon his knees, dragging the feet
after him. This had always been his gait, and by this means he constantly
excoriated the shins, which scraped along the ground as he walked; for,
from some unknown cause — perhaps from tight splintering after his nu-
merous fractures — both tibiae had become so bent forward as to leave a sharp
and very prominent angle about the middle of the bones. This portion of
the leg was protected by a leather casing, but, in spite of it, was kept con-
stantly sore from pressure as the patient walked.

In the left leg the deformity was much the greater, and, as it was also
the weaker of the two. Dr. Pancoast determined to remove it, and substi-
tute an artificial leg, by which he hoped to enable the patient to walk erect.
The amputation was done by double skin flaps, and, with the exception of
some necrosis of the tibia, the patient progressed well. Upon dissection,
the tibia was found of normal size, but flattened and bent to a wonderful
degree and rather softer than usual; while the fibula, quite translucent and
almost as thin as paper, was displaced behind the tibia, so as to be in an

1862.] Pathological Society of Philadelphia. Ill

exact line with it antero-posteriorly. The bones of the foot were remark-
ably attenuated, but the limb was otherwise normal in structure.

in the other regions of the body there was no special deformity, except
the fingers of the left hand, which were rigidly contracted as if by chronic
arthritis. But the point of special interest about the case was the apparent
paradox of coexistent mollities and fragilitas ossium ; the bones of the leg
w^ere sufiSciently fragile to break frequently from the most trivial causes,
and yet so soft as to be moulded completely out of shape by the mere ap-
plication of splints — the patient's testimony on this point being confirmed
by that of his former surgical attendants.

Incarcerated Hernia. — Dr. Lee showed this specimen, the history of
which was as follows : — ■

Andrew Wilson, between TO and 80 years old, was admitted to the Penn-
sylvania Hospital March 14, 1862. For several years he had had double
inguinal hernia, the tumour on the left side being larger than that on the
right ; and although he wore a double truss, it occasionally slipped down
into the scrotum, but was easily returned. On the day before his admission,
however, the hernia had come down and he could not reduce it. No pain
or inflammation followed, but he became alarmed and came to the hospital
for treatment. When admitted he was apparently in good condition for so
old a man ; no prostration, nausea, &c. ; and the scrotal tumour, though
exceedingly tense and hard, showed no evidence of strangulation. Nothing,
therefore, was done immediately; but after a few hours' rest he was given
a warm bath, and was afterwards thoroughly etherized by Dr. Ashhurst,
who made careful and long-continued efforts at reduction without any effect.
I understood from Dr. Ashhurst that he was under the influence of ether
fully an hour. After this he was subjected to no further treatment until
the following morning, w^hen the attending surgeon (Dr. Paucoast) arrived.
He was now again etherized, and a second prolonged but fruitless manipu-
lation was made by the attending surgeon and one of his colleagues.

Although the hernia was incarcerated only, it w^as plainly irreducible,
and from the obstinate constipation, wdiich had existed several days, the
danger of strangulation was imminent. The constriction existed at the
external ring alone, and Dr. Pancoast therefore resolved to perform an
operation which he had practised with perfect success in seven or eight
similar cases, and which he thinks was originally practised by himself,
although the suggestion is due to M. Guerin, of Paris. This consists in
puncturing the skin over the tumour, introducing a grooved director which
is pushed up subcutaneously to the external ring, and there insinuated under
the fibres of the aponeurosis of the external oblique muscle, which forms
the constriction. The position of the director being now carefully ascer-
tained through the skin, a second puncture is made with a curved bistoury
just below the raised bands of tendon, and the fibres carefully divided by
rocking the handle of the knife. In other words, the operation is one of
subcutaneous tenotomy. After this procedure w^as adopted, the hernia was
with a little difficulty completely restored to the abdomen ; a portion of the
tumour, by the way in which it returned, was clearly ascertained to be bowel.
A compress and spica bandage being applied, the patient was put to bed,
and after he had recovered from the effects of the ether a large opening
injection was given. This acted but slightly, and during the afternoon,
from the restlessness of the patient or the carelessness of the assistants,
the hernia came down again.

112 Proceedings of the [July

As soon as I discovered this I removed the bandag:e and did my best to
replace the tumour, but without success. Some pain was caused by the
manipulation, on which account the patient was given an opiate and kept
perfectly quiet. The following morning a fresh attempt was made at
reduction by Dr. Pancoast, and failing in this, he ordered the patient to be
etherized for the third time. When fully under the anassthetic, another
more patient and steady effort was made to replace the tumour, but with
no better success. Dr. Pancoast was now convinced that some undivided
bands of fibres formed the obstacle to reduction; he therefore carefully
repeated the operation of the previous day. The hernia was now returned
with perfect ease, and was retained in place more securely than before.
Dr. Pancoast remarked at the time that the more solid portion of the
tumour was hardened omentum. The patient recovered rather slowly from
the ether, was ordered a grain of opium every four hours, and that day and
the following night he did well. The next morning I noticed some difiB-
culty of respiration, with blueness about the face and nails. Auscultation
revealed marked pulmonary congestion and oedema. The opium was at
once stopped, and free stimulation, both internal and external, was substi-
tuted. Still the patient continued to sink, and died of suffocation about
mid-day. The belly was a little tympanitic, but no decided symptoms of
peritonitis existed.

At the autopsy the lungs were found completely gorged with serous
effusion, with here and there a patch of pulmonary apoplexy and much
diffused congestion; on the left side were old adhesions, while nearly a pint
of serum Avas found in the right pleural cavity. The heart was normal in
consistence, but both auricles and ventricles were filled with fluid blood; in
the left ventricle was a small fibrinous coagulum, and a few "currant-jelly"
clots, but they were extremely soft and diffluent. On laying open the her-
nial tumour, a little clotted blood was found in the subcutaneous tissue, and
the sac, indurated and thickened, was completely adherent to the tunica
vaginalis and to the cord. Its internal surface exhibited intense venous
congestion, apparently chronic; this extended about an inch above the ring
along the peritoneal coat, but no further; there was not the slightest ap-
pearance of general peritonitis, nor was the local inflammation of a very
high grade.

The neighbouring intestines were quite healthy, but on opening the ab-
domen the cause of all the trouble was at once seen in a mass of omentum
about three inches in every diameter, intensely inflamed, and so indurated
as to resemble a piece of India-rubber; from this mass the congested omen-
tal vessels spread over the surface of the omentum, gradually lessening in
intensity. The other abdominal organs were healthy.

Compound Comminuted Fracture of Thigh; Fracture of Scapula and
of Bibs, ivith hcalp Wounds and Effusion on Brain. — This specimen was
presented by Dr. Ashhurst.

Daniel McA , aged 49 5^ears, was admitted into the Pennsylvania

Hospital on the 22d of March, 1862, having been injured by being caught
in the belting of some machinery. The shock was ver^ considerable, but
he did not appear to have lost much blood.

His left thigh was found to have been fractured in its middle third, and
a small wound on the back of the limb communicated with the bone. The
main arteries of the thigh were uninjured.

The head of the humerus of the same side appeared to be prominent, and

1862.] Pathological Society of Philadelphia. 113

almost gave the appearance of an anterior luxation, but upon closer exami-
nation it was evident that the injury was a fracture of the acromial process
of the scapula, which had fallen iDackwards bv its own weight. There were
several small scalp wounds on the left side penetrating to the bone, which,
however, appeared uninjured. There was marked orbital ecchymosis of the
left side which o-ave rise to suspicion of the existence of a fracture of the
skull.

Under stimulation the patient reacted well, but towards evening he began
to sink again. At 1 A. M. his pulse was so rapid that it could not be
counted, aud his respirations 40 to the minute. He henceforth became
weaker aud weaker, and, finally, died about 4i P. M. the next day.

An autopsy was made five hours after death.

On the head there were several small scalp wounds. Some effusion of
blood under the pericranium, but no fracture whatever of the skull. Blood
was efi'used on either side of the longitudinal sinus on the summit of the
middle lobes of the cerebrum, especially on the right side. There was. also,
a small clot on the extreme posterior part of the left side at the base of the
brain. Between the membranes and upon the surface of the brain there
were about f5iij of bloody serum. The brain matter itself appeared healthy.

On the left side the acromial process of the scapula was obliquely broken
off and a ragged fracture existed in the infra-spinous fossa. The muscles
of the shoulder were infiltrated with blood.

The first rib on the left side was broken near its sternal end, the fourth
far back. The lungs and heart were healthy; the ventricles contained some
small currant jelly-like clots.

The liver was slightly fatty ; the other abdominal organs healthy.

The thigh presented a comminuted fracttire, the bone being splintered as
high as its upper third. The muscles were much lacerated, and some com-
pletely torn from their own sheaths.

Death had resulted from the effusion on brain.

April 9. Compound Fracture of Sacrum. Exhibited by Dr. Lee.

John McC , set. 45, was admitted to the Pennsylvania Hospital,

April 5, 1862, having an hour before fallen a distance of forty feet from a
scaffolding, sustaining numerous injuries. He had well-marked fractures
of the lower third of the left radius, of both bones of the right leg, and of
four or five ribs on each side. There was also a compound fracture of the
sacrum. When admitted the right lower extremity was everted and short-
ened so as to lead to a suspicion of a fracture of the thigh. This error was
at once recognized, aud while examining the pelvis a punctured wound was
observed over the sacrum; the finger introduced into this detected a frac-
ture' running transversely across the sacrum with very marked depression of
the lower third of the sacrum and the coccyx. These fragments were
jammed tightly against the rectum, which, however, was not lacerated;
reduction was efiected by means of the finger in the rectum, and required
considerable force. The patient never rallied from the primary shock, and
died in six hours. At the autopsy the sacrum was found comminuted, a
large fragment of the left ala being broken off longitudinally and disphiccd
to a considerable extent. The sixth, seventh, and eighth ribs on the right
side, besides being broken in several places, were torn from their sternal
attachment, the irregular lacerations in the cartilage being plainly visible.
Althouo-h onlv six hours had elapsed since the accident pleuritis had already
^'o. LXXXYIL— July 1862. S

114

Proceedings of the

commenced, the costal pleura on both sides being dry, rough, and intensely
injected. Contrary to expectation no lesions of the internal viscera were
found.

April 23. Compound Comminuted Fracture of Skull; Fracture of
Pelvis and Bupture of Bladder. — Dr. Lee showed these specimens with
the following history : —

Wm. Shoemaker, «t. 54, was admitted into the Pennsylyania Hospital,
in a comatose condition, at 5.30 A. M., on April 13, 1862. His friends
stated that he had fallen during the night from a second .story window, at
what exact time they could not tell, for he was only found at 5 o'clock in
the morning. His respiration w^as stertorous and blowing, and partial
paralysis of the right side existed; the left orbit was densely ecchymosed.
On examining the head a punctured wound was found near the top of the
left parietal bone, through which distinct fracture with depression could be
felt. The line of fracture seemed to extend into the frontal bone and then
across the right side, but as the man was evidently moribund no elfort to
raise the depressed bone and no further examination was made. Both ears
were so bloody that no hemorrhage or serous discharge could be made out
with certainty. He died within two hours.

Aidopsy seven hours after death. — On removing the scalp there was
found a large effusion of blood and a most extensive comminuted fracture
involving the frontal and both parietal bones, extending into the left orbit
and passing through the left zygomatic arch into the temporal bone. When
the calvaria was taken off no clot was found under the membranes at the
seat of fracture; the membranes, however, were much lacerated, and a large
submeningeal coagulum was seen at the base of the brain completely cover-
ing in the crura cerebri, and the pons ; there was, however, no fracture
whatever of the base. Before opening the abdomen a little blood was seen
trickling from the penis, and on examination a comminuted fracture of the
pelvis was discovered. This seemed to begin at the posterior part of the
left ilium, running forward to the acetabulum, where the head of the femur
w^as also indented, and, finally, involving both the ischium aud the spine of
the pubis. The jagged fragments of the latter bone had made tw^o very
large lacerations in the bladder, which w^as collapsed and lying loosely at
the bottom of the pelvis ; but the urethra had escaped injury. In the pelvis
was effused a large quantity of bloody urine which had begun to infiltrate
the connective tissue of the scrotum and hypogastrium. There also existed
fracture of four or five ribs, but the thoracic and abdominal viscera were
healthy.

Ruptured Peritoneum. — Dr. Ashhurst read the following account of a
case of this injury: —

Patrick C was admitted to the surgical ward of the Pennsylvania

Hospital on the 24th of last December, about 8 P. M. His injuries ap-
peared to be but slight. He had been struck by the cow-catcher of a loco-
motive on the Norristown Railroad, and presented a contused wound of the
brow and slight scratches on both legs. He was excessively drunk and
.troublesome. During the night he became so restless and even violent that
it was necessary to secure him in bed by means of mechanical restraint.
He now began to complain of great pain in the epigastric region.

The next morning he was sober, and evidently very dangerously ill; his
brci).thing was very difficult, and accomplished entirely by the diaphragm.

1862.] Pathological SociETir or Philadelphia. 115

the abdominal muscles being kept as motionless as possible. He was very
restless, tossing from side to side, occasionally vomiting a liquid of a dirty
green colour, constantly complaining of excruciating pain in the abdomen,
and exclaiming that he was going to die.

This state of things lasted through the morning without much change.
On going to his ward about 3 o'clock on Christmas afternoon, I found him
lying on the floor with his face downwards, having immediately before
thrown himself out of bed. He was at once taken up, but expired within
a few minutes.

An autopsy was made fifteen and a half hours after death, with the fol-
lowing results: —

Abdomen. — There was found very extensive peritonitis, with recent effu-
sion of lymph. Large clots were found in the omenta, especially the gas-
tro-colic. The left kidney was enlarged and much congested, and contained
several well-marked clots. The liver was slightly fatty.

The lungs were slightly congested, the congestion being hypostatic.

All the other organs examined appeared to be healthy.

This I believe to have been one of those rare cases of rupture of the
peritoneum without rupture of the viscera; for the left kidney, althougli
badly bruised, as shown by the clots found in its substance, did not appear
to have been ruptured.

Mr. Pollock, in his paper on Injuries of the Abdomen, in Holmes'' Sys-
tem of Surgery, considers that the first and most serious danger in ruptured
peritoneum is from hemorrhage: this is apt to be profuse if the part injured
be the omentum or mesentery, or if, as sometimes happens, the laceration
be in the peritoneum covering the pregnant uterus. If, on the other hand,
it be the parietal portion which is injured, the hemorrhage will be slight,
and the risks of inflammation are principally to be feared. The course of
traumatic peritonitis is very rapid : Erichsen refers to a case of gunshot
wound in which death ensued after twenty-four hours: there was much
serous effusion and puro-plastic matter exuded. In my case, though death
ensued only nineteen hours after admission, the appearances of inflammation
were well marked.

I have seen several cases of injury to the abdomen which at first caused
more alarm than this one, and yet which proved entirely without danger.
In one, especially, the man was squeezed between the bumpers of two heavy
cars, and when brought into the hospital was, in his own opinion as well as
in that of his friends, in a dying condition. Kest for a few days, with
sedative and anodyne fomentations, restored him to health.

May 1 4. Comminuted Fracture of Pelvis, Fracture of Thigh, &c..
Exhibited by Dr. Lee.

John F., set. 46, was admitted into the Pennsylvania Hospital April \ 2th,
1862. A brick wall, suddenly thrown down by some other workmen, had
buried him in the ruins. When brought to the hospital, his right thigh was
found broken in the upper third; the left fibula was also fractured, and a
lacerated scalp wound extended nearly half way around the right side of the
head. As some perineal ecchymosis was observed, a catheter was at once
introduced, but only after considerable difficulty, a firm obstruction occurring
behind the bulb, as if something was closely compressing the canal. Every
time a catheter was introduced the same feeling of resistance was encoun-
tered, but at the time this was attributed to the large effusion of blood in
the perineum. A careful examination made of the pelvis and other parts

116

Proceedings of the

[July

revealed no further lesion, and the man was at once put under treatment
for his fractures. For a fortnight he seemed to improve, but then became
much worse, with frequent rigors, prostration, and generally typhoid con-
dition. In this state he lingered a week longer, and then died apparently
of sh6er debility. At the autopsy, made eight hours after death,- my sur-
prise was great to find a thoroughly comminuted fracture of the horizontal
and descending rami of the pubis; a small fragment was driven through
the perineal structures and lodged immediately underneath the urethra,
behind the bulb ; this it was that had formed the obstacle to the introduc-
tion of the catheter, the urethra itself being intact, and the perineal effusion
caused by the loose fragment. The peritoneum was injected and discolored
of a brownish-green hue, with here and there patches of lymph still adhering.
There was very little effusion into the viscera, all looked healthy. Along
the periosteum covering the ends of the broken fragments of the thigh the
soft callus was seen deposited in small quantities, but nothing like an
attempt at firm union had taken place.

Dr. AsHHURST called the attention of the Society to two cases of
abscesses of the kidney.

1. Tubercle of Kidney. The diseased organ, preserved in spirits, was
exhibited in connection with this account.

Martin C . a sailor, aged thirty-two years, was admitted into the

Pennsylvania Hospital for gonorrhoea, followed by stricture and fistula in
perineo, the fistula opening in the perineal centre. The urethra was much
implicated ; irritation of both bladder and kidneys was manifested ; the
urine became loaded with pus, its reaction being acid and at no time am-
raoniacal. Death took place from colliquative diarrhoea of a few days'
duration, on the 11th of July, 1861, nearly eighteen months subsequent to
his entrance into the hospital. An autopsy made the next day revealed the
following state of things : The body was greatly emaciated, and decompo-
sition had already begun. Pleuritic adhesions existed on both sides of the
thorax. The left lung contained disseminated tubercle in various stages of
degeneration, with, however, no cavities. In the right lung the deposits
of infiltrated tubercle were yet more numerous.

The liver was yellow and fatty in appearance. The intestinal glands
were congested, but not enlarged. The left kidney was somewhat enlarged,
pale and fatty in appearance, and with the tubuli and cortical portion
blended so that it could hardly be said where the one ended and the other
began. The right kidney was of enormous size, and contained abscesses in
all parts, varying in magnitude from the size of a pea up to that of a
walnut. Some hardened masses, small in size and slightly softened in the
interior, seemed to indicate a tuberculous nature. But little kidney struc-
ture remained. The ureter much thickened, and presenting pus in its
course to the bladder, which afforded those evidences of chronic inflamma-
tion which were naturally expected.

That the abscesses in this kidney were of a tuberculous nature, may be
regarded as probable, from the fact that tubercle was found so extensively
in the lungs.

There are, according to Rokitansky, two distinct forms of renal tubercle.
The first is merely a symptom of a "very high degree of tubercular dys-
crasia,"-by which many or most of the viscera, especially those of the abdo-
men, are affected, and by Avhich both kidneys are generally uniformly
attacked, while suppuration rarely if ever ensues.

1862.] Pathological Society of Philadelphia. IIT

The second form is limited to the genito-nrinary apparatus ; though it
frequently ensues upon a tuberculous state of the lungs, while on the other
hand pulmonary tuberculosis not unfrequently follows upon the advanced
stages of this kind of renal tubercle. This form generally commences in
the testes and the lymphatic glands therewith connected, and is often
spoken of as gonorrhoeal tubercle, though no difference has been perceived
between the deposits in this and other forms of tubercle. One kidney alone
is attacked in this form, and great renal enlargement, suppuration and the
formation of abscesses of considerable size are among its characteristics.

In this class the case reported would seem to find its place, and it may
be regretted that no examination of the testes was made, as had evidence
of tuberculous deposit been found there, comparative certainty would have
been attained.

Whether the gonorrhoea, for which this patient was first admitted, had
any direct connection with the deposit of tubercle, may be doubted. If it
had, and such a connection could be shown to exist, the name of gonor-
rhoea! tubercle would not be so inappropriate as Rokitansky seems to
consider it.

2. The form of inflammation which in the kidney most frequently termi-
nates in suppuration is chronic, and arises from calculous irritation of the
pelvis. Of this condition the following case is an illustration : —

Augustus L , a seaman, twenty-four years old, died on the 3d of

August, 1861, with the condition of kidneys and bladder to be described
below.

He was admitted into the Pennsylvania Hospital for stricture of the
urethra and incontinence of urine ; electricity was applied to the neck of
the bladder without benefit. Bougies were passed and injections of lauda-
num and flaxseed mucilage into the bladder were employed without any
good result. About a week before death symptoms of acute cystitis were
developed, and the patient soon fell into a state of extreme prostration
with cold, clammy skin, running pulse, and ghastly countenance, all of
which symptoms persisted until the fatal issue. An autopsy was made
thirteen and a half hours after death, with these results : The omentum
was adherent to the abdominal parietes. The bladder was very much
ribbed and inflamed, and to its mucous surface pus and phosphates were
adherent. The kidneys were much enlarged, containing abscesses and
deposits of phosphates ; the ureters, however, were not afi'ected.

The disease in this case began, no doubt, in the kidney. That inflam-
mation beginning in the bladder should cause nephritis, without involving
the ureters, we can hardly suppose, but pus and even phosphatic formations
might pass downwards from the kidney and thus produce cystitis without
giving rise to any marked changes in the ureters during their course.

These two autopsies occurring within a short time of each other, the
patients having been admitted for the same affection (in each case stricture
resulting from gonorrhoea), and the post-mortem appearances while pre-
senting at first sight points in common, yet illustrating really far different
conditions, all these considerations have induced me to present the cases
together to the Society, as suitably accompanying each other, and illus-
trating some rather obscure points in renal pathology.

Metastatic Abscesses. — Dr. Packard gave the following account of an
autopsy in a case of so-called pi/f^mia at St. Joseph's Hospital. The
patient w^as a soldier, ast. 25, who had been shot in the right thigh, at

118

Pathological Society of Philadelphia.

[July

Winchester, five weeks previous to his death. Dr. Hunt, under whose care
he had been, made the dissection.

The wound, which was at the upper and inner part of the right thigh close
to the vessels, was first examined. An injection of solution of chloride of
zinc had been made into the artery, which vessel, as well as the vein, was per-
fectly sound. On enlarging the wound and reflecting back the skin, rectus,
sartorius, tensor vaginae femoris, and outer head of the vastus, the ball, a
large, round, leaden one, was found lying in an intermuscular space ; it had
been flattened out by striking the bone. The neighbouring muscular tissue
was in a state of fatty degeneration. On the anterior surface of the bone,
about an inch below the level of the lesser trochanter, was a depressed por-
tion, not involving the entire thickness of the wall of the bone, and having
on it a black spot which seemed to indicate the point where the ball struck.

The femoral vein was perfectly sound and healthy, as were also the iliacs
and the ascending cava. In the liver an abscess existed at the upper and
back part of the right lobe ; the organ itself was fatty, but the veins of both
systems were healthy. The pus contained in this abscess was thick and
clotty, but of a bright yellow colour; its ill-defined walls were composed of
softened gland tissue.

Abscesses were found at the posterior portions of both lungs, especially
of the left; the lung tissue in the vicinity of these abscesses did not seem to
be indurated, and there was no pleurisy apparent.

The heart was of normal size, with rather more yellow fat upon it than
is usually seen in persons only twenty-five years of age; it was full of firm
yellow clots. All the other organs seemed healthy.

This case would seem of itself sufficient to overthrow the idea that metas-
tatic abscesses are due to an arrest in the bloodvessels of the viscera of pus-
cells derived from an inflammation of the veins at some point. It is simply
presented as an additional item of negative evidence.

Deficiency in the number of Bibs. — Dr. Packard mentioned that at an
autopsy made by Dr. S. W. Mitchell, at which he was present, it was found
that the subject of the examination had only eleven ribs on each side. The
fourth rib on the left side was broad anteriorly, and joined the sternum by
a broad cartilage, perforated, as if to indicate its normally double state, by
a round hole. On the right side there was simply a broadening of the
anterior end of the fourth rib.

The case was one of rapid phthisis in a woman thirty-nine years of age.

1S62.]

119

REVIEWS.

Art. XII. — Theories of Life and Organization.

1. Becherches Fhysiologiques sur la Vie et la Mort. Par F. X. Bichat.
Nouvelle edition, precedee d'une Xotice sur la vie et les Travaux de Bichat
et suiYie de Notes par le Docteur Cerise. Paris : Victor Masson et Fils,
1862. 8vo. pp. 382.

2. De la Vie et de V Intelligence. Par P. Flourens, Membre de PAca-
demie Francaise et Secretaire perpetuel de P Academic des Sciences (In-
stitut de France), etc. Paris: Grarnier Freres, 1858. 8vo. pp. 161.

3. La Medecine Nouvelle basee sur des Principes de Physique et de
Chimie transcendanfes et sur des Ea'periencea copitales qui font
voir mecaniquement Vorigine du Principe de la Vie, Par L. Lucas.
Paris: F. Savy, 1861. Tome ler. 8vo. pp. 504.

4. La Vie dans V Homme; Existence, Fonction, Nature, Condition pre-
sente, Forme, Origine et Deatinee future du Principe de la Vie;
Esquisse Historique de V Animisme. Par J. Tissot. Paris : Victor
Masson et Fils, 1861. 8vo.

5. La Vie dans V Homme ; ses Manifestations diverses, leurs Rapports,
lews Conditions Organiques. Par J. Tissot. Paris : V. Masson et
Fils, 1861. 8vo. pp! 614-

6. Discours sur le Vitalisme et V Organicisrae et sur les Bapports des
Sciences Physiques en General avec la Jledecine: Discours prononce a
P Academic Im|3eriale de Medecine, 17 Jaillet, 1860. Par M. le Pro-
fesseur BouiLLAUD- Paris: 1860, 8vo. pp. 75.

Life-actions, their origin and cause, are still vexed questions in medical
philosophy. Notwithstanding the steady progress of the ars et scientia
medendi, during the past twenty centuries, we are compelled to admit that
the definitions and theories of life are as unsatisfactory as they are numerous
and varied. Than the existence of these theories no greater proof could
be adduced of the inherent difficulties attendant upon all investigations into
the cause of vital phenomena — dif&culties increased tenfold by the confusion
which is inseparable from such studies when pursued in accordance with the
metaphysical method.

Never, perhaps, will we be able to assign to physiology its appropriate
place among the sciences, until the great problem of life is either solved
or reduced to a determinate and intelligible formula. The scientific status
of medicine must be determined by the position and progress of physio-
logy, which is far from being an exact science. Consisting of numerous
isolated groups of facts, whose relations are by no means understood,
it is at the present moment in the same condition as was the science
of physics anterior to the time of Newton, or that of chemistry before the
era of Lavoisier. The discovery and announcement by Newton of the
gravitating law of matter, and the universality of its application, were
snfncient to stamp all the phenomena of physical science — many of them
up to that time inexplicable — with the authoritative seal of precision and

120

Reviews.

[July

exactitude. So, also, the discovery of the law of chemical affinity by
Lavoisier did much to deprive chemistry of its purely experimental and
uncertain character, and place it upon an exact philosophical basis. Com-
parative anatomy and palasontology were for a long time mere collections
of details of vague import, until Cuvier proclaimed the important law of the
correlation of forms. And now profound thinkers in our profession are
thoughtfully awaiting the advent of some medical Newton, who, with dis-
criminating mind, shall separate the true from the ''false" facts of medi-
cine, and, with enlarged conceptions of the conditions of life, seize upon
and demonstrate that great primitive fact or principle which is peculiar to
and underlies and co-ordinates all the phenomena of medicine.

It is a remarkable fact that, in tracing the history of speculation upon
the source of vital phenomena, the more we approximate the commence-
ment of the historical period, the more simple and positive do we find to
be the notions of life. In the history of philosophy no feature is more
remarkable than the pertinacity with which the ancients maintained the
existence of an independent principle or force as the primary and efficient
cause of motion and life throughout the universe. This was' essentially
the doctrine of Thales, the founder of the Ionian school, of Parmenides,
Archelaus, Heraelitiis, Deraocritus, Pythagoras, Hippocrates, Plato, and
Aristotle. The Stoics, according to Cicero, held the same opinion. Long
anterior to the time of the Greeks, we can trace it among the Hindoos^
Persians, and Egyptians. It appears to have been a fundamental dogma
in the Chaldean, Phoenician, and other ancient theogonies, and was for ages
inculcated in China by Confucius and his disciples.

After the decadence of Grecian and Roman civilization, and the estab-
lishment of Christianity, the ruling doctrine of the ancients concerning the
cause of vitality appears to have been forgotten, or altogether subverted
and replaced with the most wild and fanciful notions, which, under various
forms, continued to prevail and find advocates throughout that long and
dreary period familiar to the historian as the Dark Ages.

To become acquainted with the views upon this subject entertained in
the latter part of the sixteenth and early portion of the seventeenth centuries,
we have only to look into Harvey's work. Be Generatione Animalium,
published in 1651. In this work are embodied the notions of the illus-
trious English physiologist relative to the vital principle, life and organiza-
tion. These notions are confused, conflicting, and unsatisfactory, if not,
indeed, unintelligible. In the 71st exercise he tells us that —

" There is a spirit or certain force, inherent in the blood, acting superiorly to
the powers of the elements, very conspicuously displayed in the nutrition and
preservation of the several parts of the animal body; and the nature, yea, the
soul in this spirit and blood is identical with the essence of the stars."

This " spirit," he expressly says, is identical with the impetiim faciens
or moving power of Hippocrates. In another place he asserts that the
blood itself, by reason of its admirable properties and powers, is "spirit"
— that it is the only calidum innatum, or firi>t engendered heat, and the
immediate and competent instrument of life. He quotes Suidas to the
effect that the blood is the living principle of man, and adds that this is
true of all animals. He combats and ridicules the views of Scaliger and
Eernelius, who believed in the existence of a spirit different from the in-
generate heat, of celestial origin and nature — a subtle aura filling the
arteries, sinuses of the heart, and ventricles of the brain, and cherished or

1862.]

Tlieories of Life and Organization.

121

renewed by the act of inspiration, and, being of extreme lightness, vanishes
insensibly upon the death of the animal.

*' What occasion is there," he asks, " for this extraneous inmate, for this
ethereal heat, when the blood is competent to perform all the offices ascribed
to it, and the spirits cannot separate from the blood even by a hair's breadth
without destruction ; without the blood, indeed, the spirits can neither move
nor penetrate anywhere as distinct and independent matters."

One hundred and thirty-five years after the utterance of this language,
the celebrated John Hunter, in his Lectures on the Principles of Surgery
and his Treatise on the Blood, Ivjlammation, and Gunshot Wounds, gave
to the world his opinions upon the vital principle and the connection exist-
ing between life and organization. These opinions are worthy of examina-
tion, inasmuch as they represent very fairly the condition of the question
at the close of the eighteenth century.

" Animal and vegetable substances," says Hunter in his Lectures delivered in
1786-7, "differ from common matter in having a power superadded, totally
different from any other known property of matter, out of which arise various
new properties. * * * * -^^ Unless we consider life as the immediate cause of all
actions occurring either in animals or vegetables, we can have no just concep-
tion of either vegetable or animal matter. * ^ ^ In treating of an animal
body I shall always consider its operations, or the causes of all its effects, as
arising from the principle of life, and lay it down as a rule that no chemical or
mechanical property can become the first cause of any of the effects in the
machine. * * -h- 'yi-^q living principle, in itself, is not in the least mechanical,
neither does it arise from, nor is it in the least counected with any mechanical
principle. * * * Although life may appear very compounded in its effects in
a complicated animal like man, it is as simple in him as in the most simple
animal, and is reducible to one simple property in every animal. * ^- ^ ^ The
principle called life cannot arise from the peculiar modification of matter, be-
cause the same modification exists where this principle is no more."

So in his Treatise on the Blood, published in It 93, he writes: —

" I shall endeavour to show, that organization and life do not depend in the
least on each other ; that organization may arise out of living parts, and pro-
duce action : but that life never can arise out of, or depend on organization, *
-X- ^ Mere organization can do nothing even in mechanics; it must still have
something corresponding to a living principle, namely, some power. I had long
suspected (from about the year 1755 or 1756) that the principle of life was not
wholly confined to animals, or animal substances endowed with visible organi-
zation and spontaneous motion ; I conceived that the same principle existed in
animal substances devoid of apparent organization and motion, where there
existed simply the power of preservation."

In his Lectures on the Principles of Surgery, he tells us that —

"The living principle is the immediate cause of action in every part: it is
therefore essential to every part, and is as much the property of it as gravity is
of every particle of matter composing the whole. Every individual particle of
the animal matter, then, is possessed of life, and the least imaginable part which
we can separate is as much alive as the whole."

He acknowledges that "the simple principle of life can with difficulty
])e conceived," and proceeds to state that "the first and most simple idea
of life, is its being the principle of self-preservation, preventing matter
from falling into dissolution ; and the second is its being the principle of
action." In another place he says that "life is not action," and in still
another, that it is " the susceptibility to impression, with a consequent
power of action."

122

Keviews.

[July

Erom these quotations from his writings, it is very evident that Hunter
believed and taught —

1. That there is a vital principle.

2. That this principle is neither chemical nor mechanical in its nature,
but, on the contrary, is wholly different from any known property of
matter.

3. That it resides in, and is peculiar to, animal and vegetable beings.

4. That it is the immediate cause of all the actions occurring in these
beings.

5. That in every animal, life is reducible to one simple property.

6. That matter cannot originate life; or, in other words, that the life-
principle never can spring from, nor depend on organization,

7. That, indeed, organization and life do not in the least depend upon
each other.

8. That the principle of life is not necessarily always associated with
visible organization and spontaneous motion, but, on the contrary, may
exist in animal bodies devoid of organs and voluntary motion, and pos-
sessing but the simple power of preservation.

9. That life is diffused throughout the animal economy, every individual
particle being imbued with it.

10. That the idea of life involves and includes the principles of self-
preservation and action.

11. That life is not action, but rather the capability of action.

Such are the leading biological views of the great surgeon-naturalist of
the eighteenth century. Of some at least of these views, however, Hunter
appears occasionally to have had some uncertainty, as will be seen from the
following passages which are distinctly contradictory to some of those
already quoted. Thus, in the Principles of Surgery —

" Life appears to be something superadded to this peculiar modification of
matter, or this modification of matter is so arranged that the principle of life
arises out of the arrangement, and this peculiar disposition of parts may be
destroyed, and still the modification, from which it is called animal matter,
remain the same. If the latter be the true explanation, this arrangement of
parts, on which life should depend, would not be that position of parts necessary
to the formation of a whole part or organ, for that is probably a mechanical, or,
at least, organical arrangement, but just a peculiar arrangement of the most
simple particles, giving rise to a principle of preservation ; so that matter so
arranged could not undergo any destructive change till this arrangement were
destroyed, which is death."

Here Hunter manifestly regards life as the result of a peculiar molecular
arrangement of matter.

And, again, in the section On the Living Principle of the Blood —

" The living principle in the blood, which I have endeavoured to show to be
similar in its effects to the living principle in the solids, owes its existence to
the same matter which belongs to the other, and is the materia vitge diffusa, of
which every part of an animal has its portion. I consider that something similar
to the materials of the brain is diffused through the body, and even contained
in the blood ; between this and the brain a communication is kept up by the
nerves. I have, therefore, adopted terms explanatory of this theory; calling
the brain the materia vitse coacervata, the nerves the chordae internuncise. and
that diffused through the body the materia vitse diffusa. This latter is diffused
through .the whole solids and fluids, making a necessary constituent part of
them, and forming with them a perfect whole ; giving to both the power of pre-
servation and the susceptibiUty of impression, and, from their construction,
giving them consequent reciprocal action."

1862.]

Theories of Life and Organization.

123

In this passage our author most unquestionably identifies the vital prin-
ciple either with the substance of the brain or some matter similar to it.
His editor, Dr. Palmer, notices this glaring inconsistency, and in vain
attempts to explain it by saying that these words of Hunter should not be
taken literally. The fact is, however, that these words are but a modified
echo of the old neuro-physiology of Hoffman and Cullen — a reproduction
of the doctrine of a hypothetical nervous fluid, but in a form more substan-
tial and more in accordance with the strong matter of fact mind of our
anatomist.

Judging from his writings, Hunter's mind was eminently self-reliant and
progressive in its tendencies. More demonstrativ^e than generalizing, and
always open to conviction, he appears to have held as doubtful, and subject
to revision or modification, all theories or opinions which could not be
directly demonstrated, or which did not rest upon the most unequivocal
proofs and reasoning. Bold and independent in the pursuit of truth, he
valued opinions just in proportion as they were founded in fact. We gener-
ally find him ready to sacrifice theory to fact, whether that theory be his
own or not. We are less surprised, therefore, when Hunter, in one place,
declares that " life can never rise out of, nor depend upon, organization
and, in another, that the " principle of life arises out of the arrangement"
of matter ; when he sometimes says that the life-principle is different from
all other known agencies, and at other times identifies it with the matter
of the brain ; w^hen, in one place, he informs us that this matter is diffused
throughout the body, and in another that it has its seat in the stomach ;
when he confounds the vital principle with a "certain species of motion,'^
and, finally, acknowledges that " life is a property we do not understand,
we can only see the necessary leading steps towards it."

It is utterly impossible to reconcile such contradictory statements by sug-
gesting, as Coleridge has done,^ that the incessant occupation and stupen-
dous industry of Hunter, and his imperfect acquaintance with the arts and
aids of logical arrangement, prevented him from fully unfolding and arrang-
ing his idea of life in distinct, clear, and communicable conceptions. It is
not in consequence of this "unfriendly medium" that he falls occasionally
into the "phraseology and mechanical solutions of his age," but rather
because his views of life and the vital principle were too vague and too
unsatisfactory to himself to permit him at all times to announce these
views in positive and consistent language. It is very generally true, even
among the uneducated, that clear and distinct ideas find expression in
equally clear and simple terms ; obscure, involved, and contradictory lan-
guage is the common and suitable clothing of cloudy, indistinct, and uncer-
tain opinions. The active, progressive, and far-reaching mind of Hunter
attempted, with eminent success, to combine the practical every-day duties
of his profession with those comprehensive philosophical inquiries for which
he manifested such a strong bias, and w^hich, while they in part depended
upon the details of daily experience, in return tended to bestow upon prac-
tical medicine a rational character by the elucidation of those fundamental
principles which connect and harmonize the facts, and so really advance
the therapeutic art. Hunter, actuated with the true Hippocratic spirit,
brought reason and philosophy to bear upon experience, and steadily set
his face against all empiricism. He studied structure not for itself, nor by

' Hints Towards the Formation of a More Comprehensive Theory of Life. By S.
T. Coleridge. Edited by S. B. Watson, M. D., Philada. 1848, p. 18.

124

Reviews.

[July

itself, but with a view to function ; and he sought to explain function by
studying the economy in disease as well as in health. Hence it is wrong
to speak of him as a naturalist, or a surgeon, or an anatomist. He was
all these, and something more. He was a physiologist as well, and a phy-
siologist, moreover, who, from time to time rising above the mere details
of his science, ambitiously sought to discover that great primitive fact or
principle which, in common with many other great minds, he considered to
exist and be related to the numerous facts of medicine as the law of gravity
is to the facts of physical science and affinity to those of chemistry.

In 1793, in the Aphorismi ex Doctrina Physiologiae Chemicae Planta-
rum appended to his Flora Fribergensis Subterranea, Humboldt defined
the vital force as the unknown cause which prevents the elements from
following their original attractive forces."

"If you attentively consider," he says, "the whole nature of things, you will
discover a great and permanent difference amongst elements, some of which,
obeying the laws of affinity, others independent, appear in various combinations.
This difference is by no means inherent in the elements themselves and in their
nature, but seems to be derived solely from their particular distribution. We
call that matter inert, brute and inanimate, the particles of which are combined
according to the laws of chemical affinity. On the other hand, we call those
bodies animate and organic, which although constantly manifesting a tendency
to assume new forms, are restrained by some internal force from relinquishing
that originally assigned them. That internal force which dissolves the bonds of
chemical affinity, and prevents the elements of bodies from freely uniting, we
call vital. Accordingly the most certain criterion of death is putrescence, by
which the first parts or stamina of things, resume their pristine state, and obey
the laws of affinity. In inanimate bodies there can be no putrescence."

Shortly after the publication of these aphorisms, and during his residence
in Jena, Humboldt wrote his beautiful physiological allegory, entitled The
Bhodian Genius, which orignally appeared in Schiller's periodical. Die
Horen, in the year 1795. The language attributed in this allegory to the
philosophic Epicharmus, shows conclusively that Humboldt at this early
period of his scientific career believed in the existence of a vital force, pecu-
liar and unlike any of the forces which actuate and control the elements as
these exist in inorganic matter. He represents the " crude matters of inor-
ganic nature" as hastening at their very birth to associate, in obedience to
the laws of affinity, each with its like, and to enter into new combinations.
In animal and vegetable bodies the blending of these substances is different.
" Here vital force imperatively asserts its rights, and, heedless of the
affinity and antagonism of the atoms asserted by Deniocritus, unites sub-
stances which in inanimate nature ever flee from each other, and separates
that which is incessantly striving to unite."

Two years later (1797), his views appear to have undergone a change,
for "he declared that he by no means regarded the existence of these pecu-
liar vital forces as established."^ Writing at Berlin in 1849, he assures us
that "he has not applied the term peculiar forces to that which may
possibly be produced only by the combined action of the separate already
long known substances and their material forces." He regards the chemi-
cal relations of the elements in different bodies as better criteria by which

' Versuche iiber die gereizte Muskel- und Nerveiifaser, nehst Vermuthuugen iiber
den ehemischen Process des Lebens iu der Thier- und Pflanzenwelt., vol. ii. pp.
430-436. For a defence of the doctrine of vital affinity against the objections of
Humboldt and Daubenej, see Medical Examiner for January, 1853, p. 3i.

1862.]

Theories of Life and Organization.

125

to distinguish animate from inanimate substances than voluntary motion,
the circulation of fluids, and the internal appropriation and fibrous arrange-
ment of the elements. The difficulty of satisfactorily referring the vital
phenomena of the organism to physical and chemical laws, depends chiefly,"
he says, "(and almost in the same manner as the prediction of meteorolo-
gical processes in the atmosphere) on the complication of the phenomena,
and on the great number of the simultaneously acting forces, as well as the
conditions of their activity."

The views entertained and publicly taught by Lawrence concerning the
vital principle, life and organization, are contained in his Introducto7^y
Lectures delivered before the Royal College of Surgeons, during the years
1816, 181t, and 1818.

He regards the "functions as the offspring of structure," and "life as
the result of organization."^ He employs the term life to designate the
"assemblage of all the functions and the general result of their exercise."^
With him " organization, vital properties, functions and life are expres-
sions related to each other ; in which organization is the instrument, vital
properties the acting power, function the mode of action, and life the
result."^

''In our examination of the phenomena exhibited by living beings," says he,
" we follow a method analogous to that pursued in the physical sciences. We
trace the succession of events as far as observation and experiment will enable
us to pursue them, and we refer them ultimately to a peculiar order of proper-
ties or forces, called vital, as their causes. These vital properties are the causes
of vital functions in the same way as chemical affinity is the cause of the com-
binations and decompositions exercised among the component particles of
bodies, or as attraction is the cause of. the motions that occur among the great
masses of matter. Whatever we see in astronomy, hydraulics, mechanics, &c.,
must be ultimately referred, through the concatenation of causes, to gravity,
elasticity, &c. In the same way the vital properties are the main spring at
which we arrive, whatever phenomena we may be contemplating in respiration,
digestion, secretion and inflammation. Among the most remarkable of these
vital properties are sensibility and irritability — the power of perceiving or feel-
ing, and that of contracting. To such properties we refer in our ultimate
analysis of the functions, as the mechanician does to elasticity, when he is ex-
plaining the motions of a watch, or the astronomer to gravitation, in accounting
for the course of the heavenly bodies.* * * *

"We do not profess," he continues, "to explain l\mu the living forces in one
case, or attraction in the other, exert their agency. But some are not content
to stop at this point ; they wish to draw aside the veil from nature, to display
the very essence of the vital properties, and penetrate to their first causes ; to
show, independently of the phenomena, what is life, and how irritability and
sensibility execute those purposes, which so justly excite our admiration. They
endeavour to give a physical explanation of the contraction of a muscle, and to
teach us how a nerve feels. They suppose the structure of the body to contain
an invisible matter or principle, by which it is put in motion. iSuch is the
fiop^ow or impetum faciens of Hippocrates, the Archeus of Van Helmont, the
Anima of Btahl, Materia Vitae of Hunter, the calidum innatum, the vital prin-
ciple, the subtle and mobile matter of others.^ * * -x- * seems to me," he
proceeds, " that this hypothesis or fiction of a subtle invisible matter, animating
the visible textures of animal bodies, and directing their motions, is only an

' An Introduction to Comparative Anatomy and Physiology ; being the two
Introductory Lectures delivered at the Royal College of Surgeons, on the 21st and
25th of March, 1816. By Wm. Lawrence, F. R. S., &c. London, 1816, p. 115.

2 Ibid., p. 120. 3 Ibid., p. 121.

* Ibid., pp. 150-2. 5 Ibid., pp. 165-6.

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[July

example of that propensity in the human mind, which has led men at all times
to account for those phenomena, of which the causes are not obvious, by the
mysterious aid of higher and imaginary beings.'"

It will thus be seen that Lawrence clearly and distinctly ignores the
existence of a vital principle, and treats it as a mere chimera. Somewhat
inconsistently with the foregoing remarks, he asserts, in another paragraph,
that the peculiar phenomena of organized matter present no analogy to
those which are treated in chemistry, mechanics, and other physical sciences,
and that any reference, therefore, to gravity, to attraction, to chemical
affinity, to electricity or galvanism, can only serve to perpetuate false
notions in physiology and to draw us away from the proper point of view,
in which the nature of living phenomena and the properties of living beings
ought to be contemplated.^

Finally, as if not quite sure of his ground, he concludes with this lan-
guage:—

" To say that we can never arrive at the first cause of vital phenomena would
be most presumptuous ; but it is most true, that all the efforts to penetrate its
nature have been equally unsuccessful from the commencement of the world to
the present time."^

A year later we still find our author, in the Reply to the Charges of Mr.
Abernethy, with which he prefaces his introductory lecture of 1817, assert-
ing that " life is the assemblage of all the functions, is immediately depend-
ent on organization,* denotes what is apparent to our senses ; and cannot
be applied to the offspring of metaphysical subtlety or immaterial abstrac-
tions without a complete departure from its original acceptation ; without
obscuring and confusing what is otherwise clear and intelligible."^ He
thinks that the "notion of life is too complicated, embraces too many par-
ticulars to admit of a short definition, and varies in the different kinds of
animals as their structure and functions vary."^ He is occasionally con-
tradictory and inconsistent with himself. We have just seen that he calls
life "a result of organization." In another place he says it ''would be
unmeaning and nonsensical to call life a property of organization he
ridicules " those who think it impossible that the living organic structures
should have vital properties without some extrinsic aid," and declares that
"just in the same proportion as organization is reduced, life is reduced;
exactly as the organic parts are diminished in number and simplified, the
vital phenomena become fewer and more simple ; and each function ends
when the respective organ ceases."^

The crude and uncertain character of the biological views of Hunter,
Humboldt, and many other savants who have indelibly stamped with the
seal of their genius the scientific record of the past century, is, undoubtedly,
due to their ignorance of the true biological method. The certainty of a
science depends upon the method which rules in it and by which it is suc-
cessfully cultivated, and this method is bound up in, and indicated by the
fundamental law, the primitive fact or principle of the science. For phy-
siology, and, therefore, for medicine, which is based upon it, there is a
certainty as philosophical, though not as rigidly exact, as that which
chfiracterizes the mathematical sciences themselves. But this certainty is

' Ibid., p. 174. 2 Ibid., p. 161. ' Ibid.,p 178.

Lectures on Comparative Anatomy, Physiology, Zoology, and the Natural His-
tory of Man. By Wm. Lawrence, F. R. S., &c., London, 1848. Bohn's edit., p. 5.
^ Ibid., pp. 42, 43. ^ Ibid., p. 64. ' Ibid., p. 58. ^ Ibid., p. 73.

1862.]

Theories of Life and Organization.

127

yet prospective, and will remain so until the primitive law of physiology
and medicine is discovered and demonstrated beyond cavil.

Attempts to discover this law have not been wanting. Their history
has been recorded in the words solidism, humeralisra, vitalism, chemicism ;
in the archens of Paracelsus, the animal spirits of Descartes, and others,
the corpus pneumaticus of Bacon, the ^ther of Newton, the anima of
Stahl, the nervous fluid of Willis, Baglivi, Hoffman, and Cullen, the irrita-
bility of Glisson, the vis insita and vis nervosa of Haller, the materia vitse
of John Hunter, the vis vitse of Goertner, the excitability of Brown, the
nisus formativus of Blumenbach, the sensorial power of Darwin, the organic
spirit of Bring, the conservative principle of Blane, and the vis medicatrix
naturae of a thousand and one writers.

All these attempts were premature and more or less defective, so they
failed to establish a correct theory of life. Physiologists of the present day
possess strong reasons for believing that the establishment of such a theory
must be preceded by the formation of a positive and satisfactory theory of
organization ; a theory so comprehensive as to embrace all forms of animal
and vegetable life, from the most minute and simple to the most gigantic
and complex. Ah^eady a theory of structure, at once simple and grand,
has been erected upon the labours of many zealous naturalists and physiolo-
gists, prominent among whom are Cuvier, Bichat, and Schwann.

Both zoology and physiology are greatly indebted to Cuvier for the
progressive activity which they suddenly exhibited in the latter part of the
eighteenth century. This illustrious naturalist, who, for the comprehen-
siveness, if not the depth of his intellect, stands alone in the annals of
natural history, was the first to associate the study of the earth's strata
with the study of the fossil remains found therein ; the first, in other words,
to co-ordinate the facts and principles of geology and the physics of the
globe with comparative anatomy and physiology. It was in 1795 that he
announced the great principle that the study and classification of animals
should be founded rather upon their internal organization than their ex-
ternal peculiarities. The establishment of this principle did much to trans-
fer zoology from the hands of the mere observer of external characters to
those of the anatomical investigator and experimenter. It substituted an
exact and reliable method of classification for the artificial system bequeathed
to the world by Linnaeus. In physiology it paved the way for the solution
of the great problem of the duplex life of man, and the connection of this
life with organization. It paved the way to the elucidation of this subject
in so far as it rendered the laws of the correlation of forms and the subor-
dination of parts available to physiology. These fundamental laws of com-
parative anatomy were discovered and applied by Cuvier with the most
brilliant results. He was not slow in perceiving and duly appreciating the
wonderful adaptation of the parts which make up the living mechanism.
He saw that every organ in an animal is related to all the others, and they,
in turn, to it. Observation, comparison, and reflection, faculties which he
possessed in an eminent degree, led him to conclude that the form of an
organ being given, we might readily determine the forms of all the other
organs with which it had been associated. Thus, the form of the teeth,
and, in certain cases, even the form of a single tooth, determines the shape
of the condyle of the lower jaw ; the form of the condyle determines the
character of the glenoid cavity which receives it, and this cavity indicates
the contour of the zygomatic arch, the appearance of the temporal fossa,
&c. The form of all these parts determines the mode of mastication, and

128

PvEVIEWS.

[July

this latter expresses the form of stomach and intestines, and the kind of
digestion.

In details of this character Cuvier was eminently great. But he used
them chiefly to determine species and genera, and to found a classification
of the animal kingdom, more exact and natural than the famous system of
Linneeus. With their physiological bearing he troubled himself but little.
And this is the more remarkable since the functions are bound together by
a correlation even more intimate than that which associates the organs
themselves. Thus, respiration, when it is accomplished in a circumscribed
respiratory organ, as the lungs in man, cannot do without a circulation,
since the blood must be brought into contact with the organ which receives
the air, and it is by means of the circulation that the blood is transported
from one part of the economy to another. The circulation cannot dispense
with irritability, for this irritability determines the contractions of the heart,
and, consequently, the movements of the blood. Muscular irritability, in
its turn, is in harmony with the nervous system. If one of these functions
change, the others alter also. If the circulation is wanting, the respiration
can no longer be circumscribed. It must go on throughout the whole body,
as in insects ; for if the blood is not made to seek the air, the air must be
carried to meet the blood. The quantity of respiration everywhere deter-
mines the vigour, rapidity, and even the kind of motion. The motion
which requires the greatest muscular energy is flight ; the bird has, conse-
quently, a double respiration. It respires by means of lungs, and through-
out its whole body ; for the air having traversed the lungs, is thence con-
veyed into large sacs in the abdominal cavity, and, finally, into the cavities
of the long bones. Throughout this entire tract the blood is aerated. The
movements of mammals are more limited, and their respiration is simple.
The mammal respires by its lungs only, and these lungs are confined to one
part of the body. But its respiration though simple is complete, for all the
blood in its body passes through the lungs before being distributed to the
tissues for the purposes of nutrition. The reptilia with feeble and sluggish
movements combine a very imperfect respiration. Their pulmonary circu-
lation is only a part of the general circulation. Hence, only a part of their
blood is aerated. An impure blood circulates throughout the body, their
temperature is lessened, their movements are slow and interrupted by long
repose ; they hibernate. On the other hand, fishes, still lower in the ani-
mal scale than reptiles, have a complete pulmonary circulation ; but in so
far as it is aquatic, it is imperfect, for the air breathed is only that which is
mechanically mixed with the water. Fishes like reptiles have a cold blood,
and their movements require, in general, but little muscular energy. Thus
it will be seen that four kinds of respiration prevail in vertebrated animals ;
the double respiration of the bird, the simple but complete respiration of the
mammal, and the incomplete respiration — incomplete in two different ways
• — of reptiles and fishes. These four varieties of respiration determine four
species of motion in these animals, to wit : the flight of the bird, the walk-
ing, leaping, or running of the mammal, the crawling of the reptile, and
the swimming of the fish.

Respiration and digestion are harmonically connected. The more ex-
tensive the respiration, the more rapid and powerful the digestion. In
birds the digestion is most rapid, in reptiles it is slowest. The bird
astonishes us by the frequency of its repast, the reptile by the length of its
fast.^

' See Flourens' " Cuvier, Histoire de ses Travaux." Paris, 184r',pp. 151-156.

1862.]

Theories of Life and Organization.

129

Other examples might readily be given to show how all the organs, all
the functions, all the modifications of organs and functions are made for
each other, and for a great and predetermined object.

Enough has been said, however, to show how much the philosophy of
physiology is indebted to the Cuvierian method of contrasting animals by
their organs, instead of their external characters. But valuable as is this
method to the physiologist and the pathologist too, a still more valuable
one was indicated by the celebrated Bichat, of whom it has been said that,
" if we compare the shortness of his life with the reach and depth of his
views, he must be pronounced the most profound thinker and the most
consummate observer by whom the organization of the animal frame has
yet been studied."^ Though inferior to Cuvier in the comprehensiveness
of his knowledge, he was decidedly superior to that great naturalist in his
physiological acumen and in the grandeur of the generalizations which he
sought to establish. He boldly dealt with the most momentous topics in
biological science ; he dealt with them with a degree of enthusiasm and
laborious earnestness rarely to be met with. He investigated the human
organism with a view to obtain some clear and definite notion concerning
the causes and nature of life. He sought to establish a theory of life by
investigating the physical and chemical properties of the structural elements
of the human body. He saw that something more was required than the
mere comparison of organs. He saw in the labours of Carmichael Smyth,
Bonn, Borden, and Fallopius the germ of a great method, of a great in-
strument of research. With them he recognized the physiological value
of the tissues ; but his conception of this value was far greater and more
philosophical than theirs. With an industry almost unparalleled, he re-
solved all the organs of the body into twenty-one tissues, essentially dis-
tinct, but possessing in common the two great properties of extensibility
and contractility. " These tissues he subjected to every sort of examina-
tion ; he examined them in different ages and diseases, with a view to
ascertain the laws of their normal and pathological development. He
studied the way each tissue is affected by moisture, air, and temperature,
also the way in which their properties are altered by various chemical sub-
stances, and even their effect on the taste. Piuel informs us that in the
course of these investigations he opened in one winter no less than six
hundred bodies.

Let us contemplate the biological picture which his genius bequeathed to
us in the work whose title stands at the head of this article.

Life in the entire organic world is twofold. There is an organic or
vegetable life, and there is an animal life also. These two lives may exist
separately or in combination with each other. The former is common to
all living beings, and is strictly essential ; the latter is confined to one group
only of living beings, and is not essential to the maintenance of the organ-
ism. Vegetable life is fundamental, and upon it animal life, wherever it
exists, is superposed. Organic or vegetable life can exist alone ; animal or
relative life can exist only in combination with the former. Vegetable life,
however, is not on this account more important than animal life ; for,
although it cannot be denied that in Ijy far the greater number of organized
creatures the latter is merely supplementary to the former, yet we find, as
we ascend the organic scale, that vegetative life loses the importance arising

' History of Civilization iu England. By H. T. Buckle. Vol. i. p. C39.
2 Buckle, op. cit.

No. LXXXVIL— July 1862. 9

130

Revie-ws.

[July

from its fundamental character, and serves merely to sustain and minister
to that animal life which attains its highest expression in the moral and
intellectual attributes of man. Organic life is limited to the triple proceSvS
of reproduction, assimilation, and disintegration. Animal life exhibits
itself in spontaneous motion, and in moral, mental, and instinctive mani-
festations. The first life is for the most part internal, unconscious, and
continuous ; the second life is in the main external, conscious, and inter-
mittent. These two lives are governed by different laws, which, though
intimately connected, are to a certain extent antagonistic to each other.
They find their highest expression in man, who, in virtue of his organic
life, exists solely for himself, while through his animal life he is enabled to
move, to feel, and to judge, and is thus brought into active relation with
his fellows and with external nature in general.

Now the twofold life of man is inseparably connected with his organiza-
tion. The organism is the necessary and active medium through which
this life is manifested. We say necessary and active, for all that we know of
life is through structure, and structure eternally modifies the laws of life.
There being two lives exhibiting themselves in peculiar ways, we might
suppose, cL priori, that there are two kinds of structure — two classes of
organs. To get a good idea of the double life of man we may contrast
the organs whose actions constitute the varied phenomena of life. Only
by a careful study of these phenomena in reference to the organism, on the
one hand, and the conditions of existence, on the other, can we hope to
understand the nature of life.

The organs or instruments of the vegetable life of man are characterized
by a certain irregularity, some of them being symmetrical and some not.
Those of his animal life are remarkably and uniformly symmetrical; every-
where they exist in pairs. There are two eyes, two ears, two nares sepa-
rated by a median partition, two hands, two feet, two arms, two legs ; there
are two brains, or, rather, two hemispheres, a right and a left — two spinal
marrows, or, rather, two symmetrical halves of the medulla spinalis. All
the nerves of animal life originate in pairs, or are symmetrical. With these
facts the ancient physiologists were perfectly familiar. They drew from
the head to the foot a median line, and so divided the human body into
two lateral and symmetrical halves. Indeed, there exists an old book
written in Latin and entitled " De Homine Dextro et Sinistro," or " Man,
Right and Left."

The organs which subserve the vegetative or organic life of man are not
all as symmetrical as Bichat maintained, but are irregular, in so far as some
of them exist in pairs and some do not. Thus, the stomach, intestines,
liver, spleen, pancreas, &c. are non-symmetrical. The lachrymal, salivary,
and mammary glands, the kidneys, testicles, and ovaries are symmetrical,
as also, strictly speaking, are the penis, vagina, uterus, &c. The heart,
like the sphenoid and ethmoid bones of the skull, is symmetrical; the lungs
are nearly so in man and many of the mammals, as the lama, the rhinoceros,
and the porpoise. It is entirely symmetrical in birds, in the Chelonians,
most of the Saurians, and all the Batrachians. The branchige, or gills, are
symmetrical in all the fish, in the mollusks, in the Crustacea, and in the
worms. The tracheae are symmetrical in the insects. On the other hand,
air-breathing mollusks have a single pulmonary cavity. In the reptilian
class, some of the lizards and nearly all the serpents have one lung very
small in comparison with the other; in some of the serpents the small lung

1S62.]

Theories of Life and Organization.

131

disappears entirely. In the boas the short lung is one-half as long as the
other ; in the typhlops it is one-fourth. ^

The organs of animal life being double, while those of organic life are
for the most part single, the former life is enabled to rest, to stop part of
its functions, and to renew them again. For organic life, on the contrary,
there is no rest but in death. Organic life never sleeps. It is a stranger
to the alternations of sleeping and waking, phenomena so characteristic of
animal life. The brain may sleep, and the whole economy be benefited
thereby ; the wearied muscle may rest and come out of that rest with
renewed vigour. For the heart and the lungs there is no rest, no cessation
from toil. With them, to rest, were it even for a moment, is to die.

The wonderful processes of nutrition, disintegration, and calorification,
processes by which the living body is built up, broken down, and heated in
the self-same moment, admit of no interruption. Being single, admitting
of no supplementary aid, they are by their very nature incessant. On the
other hand, the functions of animal life are by their very nature adapted
to periods of activity and periods of repose. Who can think earnestly
while he runs quickly or toils briskly with his arms. If the right arm is
fatigued the left can relieve it. This is true of the legs, of the eyes, of the
hemispheres of the brain, &c.

The essential intermittence of animal life renders it capable of improve-
ment ; the equally essential continuousness of organic life deprives the
latter of this capability. Comparison must precede improvement. The
comparison of one state with another leads to the rectification of error in
the past or present, and its avoidance in the future. Organic life, not being
interrupted or broken into stages, is not amenable to comparison. Animal
life, on the contrary, is divided into such well-marked periods of activity
and periods of repose that its stages are eminently comparable with each
other.- It is in consequence of this repeated comparison that the unintelli-
gible cry of the infant is gradually perfected into the copious, flexible, and
glowing language of the high caste races of men ; that memory, reflection,
and judgment are matured and strengthened; that the senses are brought
to such a wonderful state of perfection ; and that the vocal muscles of the
skilful singer are enabled to produce such extraordinary musical effects.

But the theory of life promulgated by Bichat was a failure. It failed,
not, however, because the method was erroneous, but because the applica-
.tion of the method was not extensive enough. It was impossible for Bichat
to accomplish more than he did in his short, laborious, and brilliant life.
Had his life been prolonged it is difficult to say what he would not have
accomplished. We must judge him less by the results of his labour than
by, the philosophical spirit which actuated his efforts. With a loftiness of
thought to which the anatomists and physiologists of his day were entire
strangers, he attempted to connect the fundamental object of philosophical
anatomy with the fundamental theory or principle of biology. He attempted
to find the connecting link between the statics and dynamics of physiology.
Now, the fundamental object of philosophical anatomy, if we may use the
formula of Comte, is the "reduction of all the tissues to one primordial
elementary tissue, from which they are developed by modifications more
and more special and profound, first of structure and then of composition."^

^ See "Flourens' " Cuvier," edit, cit., p. 184, and " De la Vie," p. 29.

2 Comte's Philosophy of the Sciences ; being an Exposition of the Principles of
the Cours de Philosophie Positive of Auguste Comte. By Gr. H. Lewes, Loudon.
1853, p. 188.

132

Reviews.

[July

Bichat resolved all the organs into twenty-one tissues. This was a great
step. To reduce these tissues to one primordial form — the cell — years of
patient and laborious research were required by the lynx-eyed men of the
microscope. The day in which Bichat lived was not prepared for this
generalization. It was not eifected, indeed, until so late as the early part
of the present century, and the labours of very many men were required to
bring it to maturity.

The doctrine of cell-genesis, the broadest generalization at present known
to statical physiology, began with Malpighi in the recognition of the blood-
corpuscles as small globules, in the latter half of the seventeenth century,
and received many of its early facts through the industry of Leuwenhoek,
Hewson, and Haller, whose labours tended strongly to establish an indi-
viduality of organization unknown apparently to the ancients. It was not,
however, until so late as 1816, that the great idea of the structural unity
of the organic world began to take a definite shape in the minds of physio-
logists. It was in that year that Treviranus announced the broad generali-
zation that all the tissues were reducible to three morphological elements —
the amorphous, fibrous, and globular. But this announcemeiit, though
regarded as remarkable for its correctness, and far in advance of the know-
ledge of that day, was afterwards shown not to be broad enough. The
great work of Heusinger, which appeared six years afterwards, the discovery
of the nucleus of the vegetable cell by Robert Brown, in 1833, the investi-
gations of Purkinje and Deutsch upon cartilage, corpuscles, and the process
of ossification, the researches of Valentin, in 1835, upon the formation of
])igment-cells around pre-existing nuclei, and the comparison instituted by
him between the cells of vegetable tissue and those of cartilage, the obser-
vations of Sehultze upon the histology of the blood, and particularly upon
the cell-relations of the blood-particles, the labours of Henle, Yogel, Donne,
Boehm, and many others, and, finally, the announcement of the law of
developmental unity for all vegetable cells made by Schleiden in his great
work on phytogenesis, published in 1838, were all necessarily preliminary
to the discovery and enunciation of the cell theory promulgated by Thomas
Schwann, in 1839. This theory is essentially one of structure and organi-
zation, and as such should be regarded as the indispensable forerunner of
the true conception of the theory of life. Life we can study only through
or by means of its phenomena, and these are exhibited in their simplest and
most easily recognized form in the growth and development of the simple
cell — the structural unit of the entire organized world. But growth and
development, philosophically viewed, are simply modes or varieties of
organic motion. The study of life, therefore, narrows itself down to the
study of cell-motion as produced and influenced by the physical conditions
of life.^ But these conditions are many, constantly varying in intensity,
and the facts which we possess concerning them have been accumulating
for ages. Already out of these facts is now being developed a theory
bolder and more comprehensive by far than that of cell-genesis — a fitting
companion to the latter — and strictly dynamical or biological in character.
We allude to the "correlation doctrine," so-called, which seeks with no
little promise of success to resolve all the active external conditions of life
into one universal imponderable force or principle — itself, perhaps, the
essence or principle of life.

' "Daily advances in science," says Dr. Gull, in the oration delivered before the
Hunterian Society, in ISfil, " make it more and more probable that organized beings
ai'e tlie necessary development of the physical conditions of our globe."

1862.]

Theories of Life and Organization.

133

These two great theories of cyto-genesis and physico-vital correlation,
the one strnetural, the other dynamical ; the one explanatory of form and
function, the other of the active influencing cause of form and function, are
beginning to be regarded by physiological thinkers as the two broad roads
leading to a generalization more simple, more beautiful, and still more com-
prehensive than any with which biological science has yet been crowned.

Pressing on with industrious and philosophic zeal along the former of
these two roads we find Remak, Tirchow, Weber, Redfern, His, Bottcher,
Billroth, Paget, and many others. Prominent among these, for his volumi-
nous and valuable labours in this field of research, we may particularize,
without injustice to his cotemporaries, the celebrated Rudolf Tirchow, who,
following Remak in discarding the theory of the evolution of cells from a
structureless blastema, as advocated by Schleidan and Schwann, has become
the leader of the new pathological school which bears upon its banner the
fundamental doctrine — Omnis cellula e cellula.

" Especial difficulty," writes this learned biologist, " has been found in answer-
ing the question, from what parts of the body action really proceeds — what parts
are active, what passive. ***** The cell is really the ultimate mor-
phological element in which there is any manifestation of life, and we must not
transfer the seat of real action to any point beyond the cell. ***** it
is almost impossible for any one to entertain more mechanical ideas in particular
instances than I am wont to do when called upon to interpret the individual
processes of life. But I think that we must look upon this as certain, that,
however much of the more delicate interchange of matter which takes place
within a cell, may not concern the material structure as a whole, yet the real
action does proceed from the structure as such, and that the living element only
maintains its activity as long as it really presents itself to us as an independent
whole.

On the other highway of research leading to the true theory of life we
encounter, among many others, Vanuxem, Metcalfe, Grove, Carpenter,
Faraday, Mayer, Radcliffe, Hiutou, Leconte, &c.

According to Leconte there are four plans of material existence rising
successively in importance above each other. Elementary existence consti-
tutes the lowest. Chemical compounds (the mineral kingdom) form the
second. The third plane is that of vegetable existence; the fourth and
highest that of animal existence. Matter can pass from the lowest to the
highest plane only by degrees, and in consequence of a greater expenditure
■of force than is necessary to keep it in the plane of elementary existence.
Any amount of matter returning to a lower plane by decomposition must
set free or develop a force which may raise other matter from a lower to a
higher condition. "Thus decomposition," he says, "must in every case
develop force, which force may take the form of heat as in combustion, or
electricity as in electrolysis, or may expand itself in forming chemical com-
pounds, or even in organizing matter."- Decomposition, he thinks, is
necessary to develop the force by which the organization of food or nutri-
tion is effected. The egg during incubation evolves carbonic acid, and,
probably, water also, and loses weight, but gains in organization, the latter
being in proportion to the former. Heat is here indirectly transformed
into a vital force causing decomposition of a part of the organic matter,

' Cellular Pathologv, as based upon Plijsiological and Patliological Histologj. By
Rudolf Virchow. London, 1860, p. 3. "

The Correlation of Physical, Chemical, and Vital Forces, and the Conservatiou
of Force in Vital Phenomena. American Joarual of Science and Arts, vol. xxviii.
p. 305.

134

Keviews.

[July

whicli latter, by descencliDg from the organic to the mineral plane, sets free
a force which may raise the remainintr portion into a slightly higher con-
dition. The decarbonizatiou of the blood by the action of oxygen upon it,
though serving for the production of animal heat, and the removal of effete
materials, may have the higher purpose of yielding force to the blood itself
for the maintenance of its vital state. The exercise of our organs leads to
their increased growth in consequence of the fresh organizing force supplied
by the decomposition of the tissue. Indeed, to use the language of a very
suggestive contributor to the Cornhill Magazine, "there is a ceaseless
round of force-mutation throughout nature, each one generating or chang-
ing into the other. So the force which enters the plant is heat, or light,
&c., and is stored up in its tissues, making them organic ; this force, trans-
ferred from the plant to the animal- in digestion, is given out by its muscles
in their decomposition, and produces motion, or by its nerves, and consti-
tutes the nervous force."^

We have thus, in brief terms, indicated the direction which physiological
inquiry is at present taking with regard to the subject under notice. Like
two divisions of an army marching by different but converging routes to
the attack of a fortified stronghold, the students of biology are steadily
advancing along two separate paths to become masters of a theory of life
and organization which shall deprive medicine of its empiricism and give
to it a scientific and rational character. J. A. M.

Akt. XIII. — EpiJejDsy: its Symptoms, Treatment, and Relation to other

Chronic Convulsive Diseases. By J. Russell Reynolds, M. D., Loud.

London, 1861. 8vo. pp. 360.
Epileptic and other Convulsive Affections of the Nervous System, their

Pathology and Treatment. By Charles Bland Radcliffe, 31. D.

Third edition, Loud. 1861. 12 mo. pp. 312.

The method of numerical analysis has not ceased to enrich medical sci-
ence and medical art since it was first explained and illustrated by Louis.
His most distinguished English disciple. Dr. Walshe, dedicated to him a
treatise on diseases of the lungs and heart, which has become classical, and
now he himself receives from Dr. Reynolds the inscription of the most
important work which has yet appeared upon a- disease at once the most
terrible in its phenomena and the most obscure in its pathology. Thus it
is that truth grows into power. Dr. Reynolds' medical training peculiarly
fitted him for the task he undertook. Accurate and discriminating obser-
vation is at the basis of all reasoning about the causes and nature of dis-
eases; but to diseases of the nervous system none of those physical methods
are applicable which have unravelled so many knotty questions concerning
disorders of the lungs and heart, of the digestive and urinary organs. Lentil
very recently the functions of different portions of the nervous system
were imperfectly determined and consequently the interpretation of their
derangements was in a great degree conjectural. To appreciate and explain

' Physiological Riddles. Cornliill Magazine, July, August, September, and Oc-
tober, 18G0.

1862.]

Reynolds, Radcliffe, Epilepsy.

135

the phenomena of epilepsy, therefore, it became essential that the physiology
of the nervous system and the pathology of its various diseases should be
familiarly known, so that both deductively and inductively the mechanism
which produces symptomatic epileptiform convulsions and idiopathic epi-
lepsy should be demonstrated. This preparatory examination Dr. Reynolds
performed in his work on "The Diagnosis of Diseases of the Brain, Spinal
Cord, Xerves, and their Meninges," in which he showed himself a faithful
disciple of the doctrines which Marshall Hall spent his life in elucidating,
while in the present treatise he has more thoroughly combined physiological
principles deduced from experiment with the pathological inductions of a
minute numerical analysis of clinical phenomena. We greatly err in our
estimate of his conclusions if future observation shall materially impugn
their accuracy.

Dr. Radcliffe's new edition of his well-known essay is in fact almost,
as already stated in our number for January last (see pp. 198-201), a
new work, for he tells us that the whole has been rewritten and recast.
Its distinguishing feature consists in the elaborate and very ingenious argu-
ment of the author in support of the theory of epilepsy which he adopts,
and which we shall again refer to.

Since the publication of Herpin's treatise ten years ago, all writers upon
epilepsy have seen that to arrive at any correct conclusions in regard to the
nature and cure of the disease, idiopathic cases of it are alone suitable for
analysis, however useful the analogy of other spasmodic affections may be
in illustrating the nature and the proximate cause of convulsion in general.
In truth it seems now to be pretty certain that in their various forms con-
vulsion, and also paralysis, are little more than general symptoms, requiring,
indeed, for their expression, the intervention of the nervous system, but
neither denoting with certainty the particular organ of that system which
is affected, nor the nature of its derangement. Symptomatic epileptiform
convulsions, i. e., convulsions identical with those of epilepsy but attributable
to a definite organic cause, are as various in their origin as the organs of
the body from which a mechanical irritation- may be carried to the medulla
oblongata and reflected thence to the muscular system, or as the conditions
of the blood capable of exciting the specific spasms. But apart from these
there is a class of cases in which neither during life nor after death can any
starting-point be discovered for the irritation which results in convulsion,
and these we are obliged to regard as examples of true idiopathic epilepsy.
Yet it is quite possible that the time may come when even such cases may
prove to be examples in which a more recondite but not less powerful irri-
tating cause acts in the same manner as the mechanical causes of epileptic
spasm now ascertained to exist. However this may be, it is certain that
the nature and phenomena of epilepsy will be most clearly exhibited by a
searching analysis of cases in which the essential phenomena of the disease
are isolated and disengaged from all accidental conditions which would
otherwise tend to obscure them.

In a chapter introductory to the pathology of nervous diseases Dr. Rey-
nolds presents some considerations upon the nature of disease in general, in
which it is assumed that the vital actions of an organ depend upon interstitial
physical changes within it. Although it is afterwards stated that of vital-
ity and organization neither is antecedent to the other in point of time,
and however difficult it may be to conceive of life abstractly from matter,
it appears to us a doctrine fraught with danger in which such an independ-
ent existence is denied. It must still be admitted that living organized
matter being given, we can conceive of no change in the phenomena of its

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existence without a corresponding: change in its organization, or that upon
whicli its organization depends, its nntrition. Convulsions, tlierefore, must
dei^end upon modifications in the physical condition of the organs through
which they are manifested; and for convulsions of the same kind the imme-
diate or proximate organic cause must always be the same, however different
may be the remote cause. No other belief is consistent with the funda-
mental postulate of the uniformity of the laws of nature. Pr, Reynolds
assumes that the /■/' v r/ t^^^ cause of convulsions is always the same, and
consists in an al ' crease in the nutritive changes in the nervous

centres, and that the /\ causes are those which tend to induce such an
abnormal increase. Even if these propositions were admitted to be true, it
is not very clear in what manner or to what degree they throw light upon
convulsions generally, or specially upon its epileptic form. For, after all,
we must admit that lioth the proximate and remote causes are specific, since
their operation produces efi'ects sui generis : and that in idiopathic epilepsy,
no remote organic cause of it being discoverable, there is a connate predis-
position to this peculiar form of disease. The predisposition may consist
merely in the inability to tolerate or resist certain external or internal
impressions, but if it leads to epilepsy its specific causative influence is none
the less real. Again, if we admit that certain remote causes generate a
molecular condition of the nervous centres which issues in convulsions of a
particular kind, we are obliged also to admit that in certain individuals an
innate peculiar susceptibility of those nervous centres exists which implies
that they at the same time possess a peculiar molecular constitution. But
whether this peculiarity consists in something less or something more than
belongs to the perfectly normal type is purely conjectural. Quite probably
it belongs to the same category of organic conditions that create tempera-
ments, and those peculiarities of temper, disposition, and intellect which
distinguish classes of men and individuals from one another.

Leaving, for the present, the arduous question of the nature of epilepsy,
we shall follow Dr. Reynolds in some account of its phenomena. He
defines epilepsy to be "a chronic disease characterized by the occasional
and temporary existence of loss of coiiseiousiies>. witli or without evident
muscular contraction." and insists upon its I'eiiig an idiopathic disease dis-
tinct from eccentric convulsions, from tox:pirj:c sp:isnis, from the convulsions
attendant upon organic lesion of tlie cerebro-sninal centre, and, in fact,
from every other known and appreciable malady. He therefore blames
Dr. Sieveking, Bright, and others who have attempted to base a natural
history of the disease upon cases in which definite lesion.s existed equally
with those in which none such were discoverable. By the author's method,
if strictly observed, it is evident that tlie essential elements of the disease
must become disengaged from others which are only associated with it acci-
dentally. Other writers have professed to follow it, but none, hitherto,
whose accuracy in diagnosis has withstood a searching criticism.

The symptoms of epilepsy are considered under two general heads — 1,
the interparoxysmal, and 2, the paroxysmal. It is evident that a parox-
ysmal disease must be associated with some peculiarities during the intervals
between the paroxysms, however difficult ir may be to detect them in recent
cases and whenever the attacks occur at long intervals. In the present
instance, the brain being the organ which is chiefly implicated, it is only
natural, to suppose that some intellectual peculiarities should be observed.
Such, indeed, is the statement made by the greater number of writers upon
the subject; and, because idiocy and insanity are frequently associated with

1862.]

Reynolds, Radcliffe, Epilepsy.

137

epilepsy, they have often been regarded as its natural concomitants or con-
sequences. Dr. Sieveking does not remember a case "of ordinary severity"
without some flaw in the mental faculties ; but Dr. Reynolds' analysis
shows — 1. That epilepsy does not necessarily involve any mental change ;
2. That considerable mental impairment exists in some cases, but that it
is the exception, and not the rule; 3. That women suffer more frequently
and more severely than men ; 4. That the commonest failure is loss of
memory, and that this, if regarded in all its degrees, is more frequent than
integrity of that faculty. These are his most important conclusions, to
which it must be added that in thirty-eight per cent, of the whole number
of cases analyzed by him no mental alteration was discoverable.

Regarding sensational phenomena between the paroxysms, this author
finds — 1. That severe headache is an exceptional pjhenomenon, but that
slight and occasional headache is common ; 2. That women are more liable
to it than men ; 3. That vertigo also is rare, but less so in the female than
in the male sex, and is of the kind which has been termed "subjective."
In regard to disturbed motility it appears, among other conclusions — 1.
That evidences of it are presented in a large majority of epileptics; 2. That
of the three forms of motor disturbance, clonic spasm is the most frequent,
tonic spasm the least frequent, and tremor occupies an intermediate posi-
tion ; 4. That all of these forms are most common in the male sex, and
clonic spasm especially so ; 5. That their high development is most frequent
in the female sex; 6. That trachelismus is an exceptional form of muscular
disturbance ; and 7. That disorders of motility are more frequent than dis-
turbances of the mental condition.

"The general picture of the epileptic," says Dr. Reynolds, "is that of an
individual with trembling hands and uncertain movements, whose gait is awk-
ward, and whose limbs, or whole frame occasionally, exhibit startings, or present
a restlessness resembling slight chorea. It must be remembered, however, that
the picture may be that of a strong and robust man, with every movement re-
sembhng that of health and ease."

The organic condition of epileptics during the intervals of their attacks
it is of great importance to determine correctly, since a particular view of
it, and the one which is taken by Dr. Radcliffe, is closely related to the
theory of the disease which he illustrates and defends. This writer asserts
that the circulation of the epileptic is habitually feeble, and his hands and
feet cold, but Dr. Reynolds, after showing that Tissot, Portal, MaisoR-
neuve, Georget, Cooke, Miller, and Prichard make opposite statements,
proves, by an analysis of his own cases, not only that epile'psy may coexist
with phy.sical health and strength considerably above the average, but that
the. coexistence of epilepsy with such extremely robust health is more
common than its coexistence with extremely impaired health. He makes
the further remark, which is an important one, that there are no special
departures from organic health which are characteristic of epilepsy, but
that when impaired it is in the following order of functions, viz., tempera-
ture, strength, and nutrition. On the whole, and regarding the entire
state of health, animal and organic, he concludes that epileptics moderately
or slightly impaired in health are more than twice as numerous as those
whose condition is more seriously damaged.

The symptoms of the epileptic pjarojysm are considered by Dr. Reynolds
under the two forms usually described of epilepsia mitior, with local tonic
spasmodic movements, and epilepsia gravior, with general tonic and clonic
convulsion, to which are added simple loss of consciousness without con-

138

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vulsion, and o:eiieral or partial convulsion without complete loss of con-
sciousness. The simplest and mildest type is that without evident spasm,
but with a sudden and temporary, but absolute arrest of both perception
and volition, and followed by a confusion of mind, dulness of apprehension,
and depression of spirits. Or it may be preceded and accompanied by
vertigo and partial loss of muscular power, or, rather, of mental control
over it. Even if standing, the patient rarely falls, and often, as conscious-
ness returns, he resumes the action he was engaged in at the moment of
the seizure, without being fully aware of what has taken place. ISText to
this in gravity, but of greater frequency, is epilepsia mitior, in which the
degree of spasm varies from a slight contraction of a few muscles, usually
of the face, to a tonic contraction and temporary rigidity of the whole
body. It may be unassociated with evident vascular changes, or, again,
the face may be pale and the pulse feeble ; or, on the other hand, there
may be duskiness followed by flushing of the countenance and throbbing of
the heart and arteries.

We cannot follow our author in his account of the phenomena of epilepsia
gravior. It does not differ materially from that of previous writers, but it
is rendered much more complete than theirs by an analysis of the pheno-
mena, particularly in regard to their relative frequency and their succession
and combination. It will well repay perusal. In regard to that form of
the paroxysm in which there is convulsion without complete loss of con-
sciousness, we learn that it has been observed and described by several
writers, and particularly Maisonneuve, who relates four cases. Dr. Rad-
cliffe furnishes an example, and Dr. Reynolds five others, of this singular
form of disease. In one of these, the symptoms were those of sudden tonic
contraction in the muscles of the face and neck, with suffused face, embar-
rassed respiration, twisting of the head, and slight tremulous rigidity of
the arms, the whole lasting from three to five seconds, and the patient not
only affirming afterwards, but evidently exhibiting at the time, persistent
consciousness. In regard to the epileptic aura, the author states that he
never met with anything like that described by the old authors under this
name, but in one case the jerking of an arm, and in another the drawing
up of a leg, extended apparently towards the trunk, and passed into a
general paroxysm so soon as it reached the latter ; in a third case, a stab-
Ibing pain in the arm preceded the attacks ; and in all these the fits might
occasionally be arrested by grasping firmly the thigh or upper arm, or by
forcibly extending the limbs.

Under the general head of the etiology of epilepsy we find that Dr. Rey-
nolds' experience leads him to believe that an hereditary tendency to the
disease is much more common than it is generally represented to be by
recent writers upon the subject. In regard to age and sex, the analysis of
his observations teaches that the approach of puberty is a powerful predis-
posing condition, and that females under ten and males above twenty years
are most likely to become epileptic. A case is mentioned in which the first
attack occurred at the age of seventy, and without any assignable cause.
In about one-fourth of his cases Dr. R. could discover no cause whatever of
the attacks, and in nearly one-fifth the cause was doubtful; of the remainder,
psychical causes were equal in number to all of a physical nature, including
in the latter category eccentric irritation, general organic changes, and- the
action of external agents.

If we seek to learn the natural history and relations of the different
forms of attack we find that epilepsia gravior is twice as frequent as epilep-

1862.]

Reynolds, Radcliffe, Epilepsy.

139

sia mitior ; but that for the latter to exist alone is an excessively rare
occurrence. Yet it is not a preliminary stage out of which the graver
form of the disease is subsequently developed, nor, on the other hand, is
it an after consequence of that form; but it is an attendant pheno-
menon, absent in some cases, and occurring in others, but at no particular
period in the development of the disease. According to the author's expe-
rience, which agrees with that of Delasiauve, regular periodicity is excep-
tional in epilepsy, and in only three women could he detect any habitual
relation between the attacks and the catamenial state. At the same time
he admits that in a majority of cases there is an approximation to periodi-
city in the recurrence of the attacks. Important conclusions relative to the
influence of frequency of attack are these ; frequency of attack and mental
deterioration are more commonly associated than are opposite conditions;
a high rate of frequency is more commonly associated with slight degrees
of motor disturbance ; and while individuals whose attacks were of very
frequent occurrence exhibited, positively, no defect in their general health,
those, on the contrary, in whom the organic condition was much below par,
presented only a low rate of recurrence. "It is evident, therefore, that a
high rate of frequency of recurrence is not determined by organic ill health ;
but that, on the contrary, a notable frequency of attack is associated with
unimpaired general health." Nor is there any constant relation between
the age of the patient and the rate of frequency of the attacks ; for, although
they are most apt to recur frequently in persons under the age of seventeen
years, youth by no means necessarily entails a high rate of frequency.
Indeed, when the commencement is very early, as during the first twelve
years of life, the rate of frequency is commonly low. Nor, again, has the
total duration of the disease any relation to the frequency of the attacks.

The mental condition associated with epilepsy is a subject of peculiar
interest, for it has been generally believed that sooner or later in the pro-
gress of the disease the mind becomes impaired, and reason is lost in
dementia or mania. A close analysis of cases, however, proves that there
is no relation between mental failure and a hereditary predisposition to
epilepsy, nor any between this state of mind and the age at which the dis-
ease commences, nor between this state and the mere duration of epilepsy.
It appears, however, contrary to Esquirol's opinion, that when epilepsy
commences after puberty the intellectual condition is impaired more rapidly.
When the general organic health is exceedingly good there is a greater
tendency than exists in epileptics per se, to deterioration of the mental
condition; but so soon as the general health fails, and in the degree to
which it fails, does the mental condition relatively improve. At the same
time, the mental condition of epileptics cannot be v/holly referred to their
state of general health, for a sound state of mind or any degree of mental
failure may coexist with perfect organic health, or with the opposite con-
dition. Just as little can the mental failure of an epileptic, or its degree
when present, be referred to the number of attacks he has experienced, but
it has a constant and direct relation to the frequency of the seizures. The
converse is not, however, true. Frequency of seizure is not necessarily fol-
lowed by mental failure; it is one, but neither the sole nor a necessary con-
dition of this result. Again, it follows from Dr. Reynold's analysis that
when attacks of E. mitior are present the mind is more frequently affected, and
affected gravely, than when the individuals are free from the slighter seizures.
Yet, as these may exist without entailing mental incapacity, it follows that
they are not essential to the result. This author concludes, that while

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neither form of attack necessarily entails npon the sufferer mental injury,
yet when both forms coexist mental failure occupies a more marked and a
more direct relation to attacks of E. mitior than to those of E. major.
These conclusions materially modify the general statement of Dr. Radcliffe
that "the natural tendency of epilepsy is assuredly towards dementia,-' even
when qualified as it is by the admission that it is possible for an epileptic
to liv€ many years, and to have many fits without losing the powers which
are necessary to render him an agreeable and serviceable member of society.
(P. 139.)

In regard to the motor condition, and its state in regard of general
organic health, Dr. Reynolds shows that those individuals in whom tremor,
clonic, and tonic spasm are present do not exhibit any higher rate of fre-
quency of attacks than do those from whom such disturbances of motility
are absent, and, therefore, infers that the causes of the attacks and of the
disturbances alluded to are not identical, and that neither is the cause of
the other. Nor is there any constant relation, and, therefore, not any in-
ter-dependence between tremor, clonic spasm, or tonic spasm, on the one
hand, and deficiency, nutrition, strength, or temperature on the other.
Tremor and also clonic spasm are apt to be associated with impaired strength
and temperature ; but tonic spasm does not affect the nutrition.

It is remarked by Dr. Reynolds that in describing the consequences of
epilepsy sufficient care has nat been taken to distinguish between conditions
which may properly be so called and those which are due to other diseases.
An examination of his own cases leads him to the conclusion that the
duration of epilepsy exerts a slight and only doubtful influence upon the
patient's health, and it is quite as likely to be impaired in a recent as in a
protracted case. He also infers from the same data, that " epilepsy does not
produce, i. e., that it, per se, does not cause failure of memory, of apprehen-
sion, or of ideation, tremor, clonic spasm, or tonic, loss of nutrition, tem-
perature, or strength." And he shows that the opposite opinion is attri-
butable to the very heterogeneous character of the cases denominated
epilepsy, which have served as materials for the greater number of those
who have written concerning the disease.

The proper complications of epilepsy, or " those conditions which may
be held to depend more or less directly upon the attacks," are few in number.
Epileptic mania, the author remarks, has a character of its own. Gener-
ally furious, sometimes ecstatic, in other cases it is marked by dulness and
depression of spirits ; or, on the other hand, by preternatural gayety.^

Apoplexy would seem, d priori, to be a very natural termination of the
repeated and violent attacks of congestion of the head which are charac-
teristic of the fully developed attack of epilepsy. But, as in so many other
instances, experience contradicts the anticipations of, we will not say science,
but reasoning; Dr. Reynolds assures us that "it is exceedingly rare to find
that actual hemorrhage has occurred;" and adds, "no single instance of
such an occurrence has presented itself in my own experience." He is

' Upon this subject the reader will consult with interest and advantage a memoir
hj M. .Jules Falret {Archives Generates de Mid., Dec. 1860, and Avril and Oct. 1861).
The author describes minutely different phases of mental aberration with an incon-
trollable propensity to commit violence wliich characterize the vertiginous and
convulsive forms of epilepsy, and those cases in which the epileptic character of
the disease is unrecognized or misconstrued. The subject is one which demands
the attention of the medical jurist, and it is particularly in its relations to criminal
law that M. Falret has illustrated it.

1862.]

Reynolds, Radcliffe, Epilepsy.

141

unable to trace the character of the relations between idiocy and epilepsy.
Of poTaJysis he makes the same remark as of apoplexy. It stands in an
accidental, not an essential, relation to epilepsy.

The patJioIof/y of epilepsy is discussed by Dr. Reynolds in a very able
manner. He brings to its elucidation a thorough acquaintance with all the
most recent results of anatomical and physiological investigation, and sub-
jects them to a rigid criticism guided by the only sufficient test, clinical
experience. Unfortunately, clinical experience is apparently not uniform
and consistent in its teachings, for it is invoked with equal confidence by
those who maintain the most opposite doctrines. This is true even in
regard to pathological questions, the elements of which are comparatively
stable and readily appreciable by the senses; it is much more so when the
phenomena to be studied are fluctuating and not uniformly associated with
the same, or, it may be, w^ith any material change of structure.

Dr. Reynolds propounds the following questions : 1. What is the organ
on whose modifications the symptoms of epilepsy depend ? 2. What is
the nature of its change ? 3. How was that change induced ? 4. What
are the links of connection between that change and the phenomena of the
disease ?

To the first question pathological anatomy answers, 1, that no structural
change is constantly found at all periods of the disease ; and 2, that some
lesions are of more common occurrence than others. But as none are uni-
form, or even approach to uniformity in occurrence among the lesions which
may be considered as efficient causes of epileptic phenomena, no one of these
lesions can be regarded as the essential cause of the paroxysm. The obser-
vation of Sehroeder van der Kolk, that enlargement of the capillary vessels
and granular degeneration of the medulla oblongata are to be found in the
bodies of epileptics is very important and significant; but this observer
himself speaks of the lesions in question, not as the causes, but as the
"proximate result of the fits." Physiological experiment furnishes a dif-
ferent answer, while it corroborates the conclusion just expressed. Brown-
Sequard, Kussraaul, and Tenner have proved by experiments upon animals
whose cerebral hemispheres and cerebellum had been removed, that epilepti-
form convulsions may be excited in them by irritation of the medulla oblon-
gata, and that this irritation may act efficiently whether it be applied directly
to the nervous centre in question or indirectly to it and to the spinal marrow
by irritating the remote branches of nerves supplying the skin and other
organs. But convulsive movements do not constitute the whole of epilepsy.
Its more characteristic symptom is the loss of consciousness which attends
tliem, and which necessarily implies some changed condition in the cerebral
hemispheres. The ancient opinion prevailed until recently, and was accepted
and extended even by Marshall Hall, that the phenomenon in question is
due to congestion of the brain. Yet it is evident that the evidences of
cerebral congestion present themselves late in the paroxysm, whereas loss
of consciousness is its earliest symptom. It had long ago been shown by
Sir Astley Cooper that compression of the carotids and consequent anemia
of the brain will induce loss of consciousness and epileptiform attacks.
Clinical observation furnishes abundant proof of the same pathological
fact. Dr. Brown-Sequard and others have demonstrated that the arteries
of the brain-meninges contract through reflex stimulation, the centre of
such a reflexion being the medulla oblongata.

"There appears, therefore," says Dr. Rej'nolds, "no reason for doubting that
the immediate cause of loss of consciousness is arrest of the cerebral circula-

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[July

lion, owing to the contraction of the vessels, through irritation propagated
along the vaso-motor nerves from the medulla oblongata ; and thus the latter is
shown to be the organ wherein both elements of the epileptic paroxysm have
their origin."

Not that this nervous centre originates those elements, but only that it
is the channel through which the organic causes operate to produce the
phenomena of the attack.

What, then, is the nature of the morbid change ?

"In early cases," says Dr. Eadcliffe, citing the conclusions of Schroeder van
der Kolk, " in early cases of epilepsy, it is true, we may fail to find anything
characteristic even here [?". e., in the medulla oblongata] ; but in confirmed cases
this organ is harder than natural, from the interstitial deposit of a minutely
granular albuminous matter, or else softened, swollen, and presenting evident
signs of fatty degeneration. The posterior half is also redder and more hyperae-
mic than it ought to be, even when the patient had not died in a fit; and on
making a more minute examination, the bloodvessels are seen to be dilated to
thrice their natural dimensions, and with their walls much thickened. These
vessels, moreover, are seen to be especially dilated in the course, of the hypo-
glossus nerve and corpus olivare in epileptics who were in the habit of biting
their tongue in a fit, and in the course of the roots of the vagus in epileptics
who were not in this habit."

But all of these changes are, as we have already seen, effects and not
causes of that which occasions epileptic convulsions. In the early attacks,
Dr. Reynolds remarks : —

"Nutrition is affected dynamically and temporarily; there is no recognizable
departure from textural integrity ; there is merely the difference that exists in
health and in all organs between action, over-action, and repose ; after a time,
and by frequent repetition of attacks, the changes, induced temporarily, become
permanent, and the texture, which is the product of foregone nutrition processes,
is altered statically and persistently."

Now, as regards the nature of the irritation which determines the con-
vulsive attacks, it must be borne in mind that all the movements of the
respiratory and other organs upon which the sustenance of life depends,
are reflex actions, as well as many others which can also be performed by
the operation of the will. Dr. Reynolds reminds us that the unconscious-
ness of the epileptic paroxysm has its analogue in ordinary sleep, a state
w^hich has never yet been explained, and that under the influence of emotion
the phenomena of convulsions occur in daily life and as parts of our healthy
activity. The conclusion must therefore be that in epilepsy the functions
of the reflective centre are changed in degree rather than in kind.

But if changed in degree, is there increased or diminished action ?
Upon this question Dr. Reynolds and Dr. Radclifife arrive at diametrically
opposite conclusions, the one finding in all the phenomena of the fit " evi-
dence, not only of disturbed equilibrium, but of distorted, misdirected, and
exaggerated power," and the other concluding that the facts adduced by
him " will scarcely warrant the idea that epilepsy is connected with any-
thing like over action of the nervous system." Dr. Radclifife attempts to
show by a very ingenious induction that the blood, instead of being a
stimulus to muscular contraction, tends, on the contrary, to prevent it,
and that its withdrawal promotes first irregular muscular contraction, and
finally, after death, tonic rigidity. In like manner, after a long experi-
mental and rational inquiry, it seems to him " no improbable idea that
muscular elongation is coincident with the presence of electrical action in
Biuscle and nerve, and that muscular contraction is coincident with the

1862.]

Reynolds, Radcliffe, Epilepsy.

143

absence of this action. It would seem to be no improbable idea that there
is a state of polarity in living muscle during relaxation which produces
relaxation, and that contraction is nothing more than the necessary result
of the muscle being liberated from this state." Relaxation, then, is,
according to Dr. Radcliffe, the active condition of muscular fibre, contrac-
tion "nothing more than the necessary result of the muscle being liberated
from this state, and left to the operation of the attractive force which is
inherent in the physical condition of the muscular molecules." Applying
this theory to the phenomena of epilepsy. Dr. Radcliffe maintains that the
activity of the medulla oblongata, so far from being augmented during the
attack, is deprived of its normal power and abandons the muscular system
to its inherent organic contractility. Upon this view we think it would
be sufficient to remark that it renders extreme if not insurmountable the
difficulty of explaining the clonic character of epileptic convulsions. It
adapts itself, as the author shows, to the phenomena of rigor mortis, and
in some degree to those of tetanus, but it leaves unexplained the source
from which convulsed muscles derive the power of regaining their normal
condition, since, according to the hypothesis, they begin their morbid con-
traction with a loss of power.

But to return to the question of increased or diminished action in epi-
lepsy. As Dr. Reynolds very appropriately remarks, the terms " action"
and " over-action" used in reference to the medulla oblongata imply both
the capacity for receiving impressions and the faculty of giving forth motor
impulse. In epilepsy the former appears to be constantly in excess, as Dr.
Brown-Sequard has pointed out, and this is almost the sole causative ele-
ment of the paroxysm in epilepsia mitior, whereas in the graver forms of
the disease motor excitability is predominant. , The susceptibility of the
motory nervous centre is proved even between the paroxysms by the readi-
ness with which the nervous equilibrium is disturbed and attacks are pro-
duced by emotional or moral commotion. This double exaggerated suscep-
tibility of the functional activity of the medulla oblongata and upper part
of the spinal axis appears to be the immediate cause of the convulsive
phenomena of epilepsy. But what awakens it and with it the convulsive
and other characteristic phenomena of the disease ? Undoubtedly in many
cases an eccentric irritant may be detected, or something which may be
held to act as such, although the supposed causes differ from one another
as. widely as organic disease of the brain, mental excitement, the mechanical
irritation of a distant nerve, and some more or less definite vitiation of the
blood. But in many other cases no such influence can be demonstrated,
and we are therefore compelled to admit a peculiar and innate susceptibility
to the disease. Such a susceptibility it is doubly imperative that we should
recognize when epilepsy is purely hereditary, or the causes which develop
it are of slight intensity, or appear to acquire their morbid influence by
frequent repetition. Of the latter class are those excitations which induce
a state of the organism analogous to the epileptic condition.

" In this manner," says Dr. Reynolds, " pertussis passes into convulsion —
coition or masturbation into epilepsy ; and in the same way the latter has been
developed by violent laughter from tickling the feet."

"The facts would appear to show," says Dr. Radcliffe, "that the habitual
state between the paroxysms of ordinary epilepsy is one which is marked by a
weak and slow pulse, by cold extremities, and by shallow, or retarded, or sighing
breathing, and which is most marked in this manner when the danger of the
attack is most imminent."

144

Reviews.

[July

And again : —

" The interparoxysmal state in ordinary epilepsy is marl?;ed by wanting vigour
both in the circulation and in the respiration."

But debility is denied by Dr. Reynolds to exist in more than one-half of
the cases of epilepsy. He also proves that, instead of a low condition of
vitality favouring the recurrence of the fits, the reverse is true ; and the
paroxysms are shown to be most frequent and severe in those whose organic
vigour is unimpaired. Moreover, in this class of patients both forms of
the disease, E. gravior and E. raitior, are apt to be combined, whereas in
impaired health E. gravior is mainly the form which the paroxysms assume.
Again, as we have already seen, the mental power has a stronger tendency
to deteriorate when the general health is remarkably good, and relatively
to improve when the latter declines. Such are among the results of a
clinical study of epilepsy, and, as Dr. R. remarks, it is not a sufficient
answer to assert that debility is the cause of convulsion in that disease,
however clear the evidence may be that cerebral anaemia is a cause of con-
vulsion. Convulsion is not epilepsy, but only one of its symptoms.

Among the conditions favourable to the production of epilepsy, the
cachexia? are often excited, probably for no better reason than that, because
a tangible and demonstrable cause could not be discovered, the equally
mysterious conditions denoted by the name just mentioned might be accused
without much risk of their innocence being demonstrated. Dr. Reynolds
states that fifty-six per cent, of the epileptics examined by himself were
free from all cachexia ; they were in perfect health of body. We cannot
but feel surprise that so acute a physician as Dr. Radcliffe should cite,
apparently in support of this doctrine, a passage like the following, which
it is little to the credit of Dr. Todd that he should have written : —

" I hold that the peculiar features of an epileptic seizure are due to the gradual
accumulation of a morbid material in the blood, until it reaches such an amount
that it operates upon the brain in, as it were, an explosive manner ; in other
words, the intluence of this morbid matter, when in suflBcient quantity, excites
a polarized state of the brain, or of certain parts of it, and these discharge their
nervous power upon other parts of the cerebro-spinal centre in such a way as
to give rise to the phenomena of the fit."

It would be difficult to find anywhere a greater number of gratuitous
assumptions and illogical deductions crowded into so small a space as in
these few lines.

Certain conditions of the economy, however, appear to act as determin-
ing causes of. epilepsy. In some of them, it is true, local centres of irrita-
tion exist, which may operate by a reflex agency, as in puberty, pregnancy,
and dentition ; in others, smaller in number, there is a morbid nutrition
change, as in rheumatism and pneumonia. The real value of these elements
as causes of epilepsy will depend upon the degree of predisposition to the
disease in cases where they appear to develop it. and this, according to
Dr. Reynolds' observations, appears to have been very decided.

The last mode mentioned by this author in which the medulla oblongata
and the upper part of the spinal axis may become so affected as to produce
epileptiform convulsions, is the operation of some lesion of the nervous
system, such as a cerebral or spinal tumour, chronic meningeal inflamma-
tion, softening of the brain, neuromata, &c. ; but he repeats the important
oljservation that the clinical history of these cases differs from that of
idiopathic epilepsy, in that they present superadded phenomena dej-ending
upon the character of the local lesion iti each case.

1862.]

Reynolds, EADCLirrE, Epilepsy.

145

Having thus attempted to elucidate the- morbid nature of epilepsy, the
author proceeds to a rational explanation of the various phenomena of
the paroxysm. In the first stage, as already explained, loss of conscious-
ness is attributed to the arrest of the vascular supply by spasmodic contrac-
tion of the cerebral vessels ; tonic muscular contraction to undue action in
the medulla oblongata passing dovrnwards to the spinal cord; arrested
respiration is attributable to closure of the glottis, to fixation of the re-
spiratory muscles, or to both combined, the second agency being the most
operative by far. The epileptic cry he regards as a spasmodic phenomenon,
and not as expressing distress ; and pallor of the face as produced by the
same sort of hifluence which occasions loss of consciousness, viz., spasmodic
contraction of the arteries. This explanation of the former ^symptom
originated with that singularly sagacious observer Whytt, whose great
merits it has required the lapse of a century to disclose. Duskiness of the
face is admitted to be caused by the trachelismus" of Dr. Marshall Hall,
by whicl? the return of the blood through the cervical veins is prevented.
Dilatation of the pupil is, like pallor, the result of over-action in the dilat-
ing fibres of the iris ; and feebleness of the radial pulse is due either to
muscular tonic spasm concealing it at the wrist or arresting it at the
shoulder.

In the second stage, continued loss of consciousness is owing to conges-
tion rather than anaemia of the cerebral hemispheres, " In the first stage
the epileptic's brain had no action — now it has a morbid action ; in the
former it may be said to have been dead or defunct — in the latter to be
poisoned or narcotized." Clonic convulsion is a consequence of the circu-
lation of carbonized blood ; laborious respiration and tracheal gurgling
are obviously effects of asphyxia primarily induced by tonic spasm, as are
also palpitation of the heart and throbbing of the arterial pulses. It is
during the clonic stage that the contents of the bladder, rectum, and vesi-
cul83 seminales are discharged, and that profuse lachrymation and salivation
occur. These phenomena are all due to pressure upon the several receptacles
and glands. The after stage of stupor," when this exists, is one of ex-
haustion and partial paralysis, and its severity appears to be "in proportion
to the amount of asphyxia, the latter being determined by the duration of
the tonic stage of the attack." From an analysis of the conditions under
which the epileptic aura is observed, the author regards it as a peculiar
induced condition of the peripheric expansion of certain centripetal nerves,
and this one of exalted impressibility or functional activity. When thus
changed, these nerves are capable of setting up abnormal motor reactions
upon the application of slight stimuli.

The phenomena of the interparoxysmal condition, in their relation to
the central fact of the disease, are explained by Dr. Radcliffe as follows :
As to mental failure, it is important to observe that this does not exist iii
more than one-third of the cases ; in the others it is very analogous to the
decay which accompanies old age, and results chiefly from incapacity for
attention, which in its turn is associated with a listless indifference to every-
thing. As we have already seen, it is not proportioned to any of the phe-
nomena of the disease, and Dr. R. thinks it must depend " upon a peculiar
condition of the brain, induced (but only in some individuals) coetaneously
with that which is the cause of the paroxysms." That this deterioration
of the functions of the brain is due to its impaired structure is most pro-
bable, because it is in direct proportion to the frequency of the attacks.
No. LXXXYIL— July 1862. 10

146

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[July

Time is therefore wanting for the complete repair of the damage which the
brain's structure has sustained during the paroxysm.

The chapter on Diagnosis, as might be expected, illustrates the peculiar
skill of the author in a field in which he has already been distinguished. The
greater number of convulsive affections are in little danger of being con-
founded with epilepsy by acute and accurate observers. Eccentric convul-
sions, although individually presenting all the phenomena of epilepsy, do
not constitute that disease. If the irritating cause which occasions them
is removed before they have had time to produce organic changes in the
brain, they cease to occur. As Dr. Reynolds remarks, the distinction is a
real one, and of the highest importance in the direction of treatment.. In
one word, it is essential to the idea of epilepsy that its paroxysms should
arise in the first instance, and recur at intervals subsequently without the
operation of the same definite exciting cause. Similar remarks are appli-
cable to toxasraic convulsions. As to those which proceed from tumours,
softening, chronic meningeal inflammation, &c., of the brain, tjie inter-
paroxysmal symptoms, if attentively observed, will generally afford sufficient
ground to base a diagnosis upon. .The distinction of such diseases from
one another is not involved in the present discussion. In general terms,
these groups of organic cerebral disease differ from epilepsy in the following
particulars : —

" There is extreme irregularity in the period of recurrence of convulsions
symptomatic of cerebral disease. Their appearance is preceded and accompa-
nied by aggravation of the other symptoms, and often followed by the develop-
ment of new phenomena. The attacks have rarely all the characters of fully
developed epileptic paroxysms ; either consciousness is partially retained, or
there are no asphyxial changes ; or the irregular spasms continue for a much
longer period ; or they are confined within narrow limits ; or they are not fol-
lowed by coma."

Of the prognosis of true epilepsy, Dr. Reynolds offers no flattering ac-
count. Out of eighty-one cases, eight only absolutely recovered, or ten
per cent. Various circumstances influence the prognosis. Thus, when the
cause is most obscure, there is most reason to apprehend the existence of a
strong inherent proclivity to the disease, and, therefore, to indulge but a
slender hope of removing it. In regard to age. Dr. R. found, at the time
of the fits ceasing, the age of his patients that recovered was between fifteen
and thirty-two, and the disease had commenced at ages between thirteen
and thirty-one. In regard to the mental condition of epileptics, the pre-
sence of hereditary predisposition appears not to exercise an unfavourable
influence; but the reverse is true as regards the female sex, and the com-
mencement of the disease after childhood and puberty. As a general rule,
when the mind has suffered much, it has suffered early. It has been already
stated that intellectual impairuient is more commonly associated with a
vigorous condition of the health than with the reverse. The danger to
life in an epileptic is a somewhat remote contingency; and in true epilepsy
the attacks rarely leave behind them either paralysis or other change of
motility, or any notable injuries to the organs, or functions of special
sense.

We were not surprised to find so small a portion as only thirty pages of
Dr. Reynolds' work devoted to the treatment of epilepsy, and half of these
to the narration of illustrative cases. From his point of view the records
of cures of this affection are not trustworthy, because they comprise ^11

1862.]

Reynolds, Radcliffe, Epilepsy.

147

epileptiform convulsions as well as simple idiopathic epilepsy. To sepa-
rate the two categories from one another, and accurately estimate the value
of the therapeutic element in each, would be impossible. The records of
the last twenty years are less chargeable than earlier ones with this defect,
but they are by no means free from it. As Dr. Reynolds remarks, "The
first essential is diagnosis : organic disease of the brain, diathetic disease,
and eccentric convulsions must be eliminated carefully: we must know what
we have to treat." This is an unquestionable truth ; and when we observe
how it has been neglected in the purely empirical treatment of the disease,
we cannot feel surprised at the farrago of drugs to which anti-epileptic
virtues have been attributed. On the other hand, we are indisposed to
subscribe to the proposition that the rationalistic method has failed " in a
still larger number, because the theories upon which it has rested have often
been abundantly wrong." Had the theories been demonstrably true, they
would never have served as a basis for treatment — they would only have
accomplished what the author of this work has so happily attempted, and
furnished to the physician cases identical in their nature, in the treatment
of which he would still have been obliged to employ remedies empirically.
The disease isolated by observation, and the remedy discovered empirically,
are the two essential factors in all scientific cures.

When, therefore, Dr. Reynolds lays down, as indications in the treatment
of the epileptic condition, "the reduction of undue excitability," and "the
improvement or the maintenance unimpaired of the mental powers and the
general health," and mentions as means thereto " the administration of
sedative medicines, the establishment of counter-irritation, and the main-
tenance of a certain regimen," he merely formulates what universal empiri-
cal observation has taught. Science endeavours to justify art, but does
not add a tittle to the powers of art; she may prevent a wasteful expendi-
ture of art's resources, but renders them not a whit more or less intrinsically
valuable. The indication "to reduce excitability" is not a discovery of
science, it is the instinctive teaching of common sense. Nothing is practi-
cally gained by formulating in those words what the records of medicine
show was in every physician's mind from the beginning. "Excitability,"
as we call it, was patent in the muscular and other disordered phenomena
of the disease ; experience had taught the power of certain agents to allay
disorders more or less similar to those of epilepsy; and these agents, which
afterwards were designated by the common epithet, narcotics, were resorted
to in the hope of curing epilepsy also, i. e., the convulsive disorder which
appeared to constitute the disease. It were well, therefore, that we should
remember that the natural growth of knowledge is inductive, and always
proceeds from particulars to general propositions, and that any of the latter
not so developed are generally fallacious, if not necessarily false.

In reviewing the particular narcotics and sedatives which are intended to
fulfil the indication of "reducing excitability," Dr. Reynolds relies, perforce,
upon the testimony of experience, and includes in his list agents as different
as opium and hyoscyamus, conium and belladonna, Indian hemp and Selinum
palustre. From what we know of the mode of operation of these medi-
cines it would be difficult to refer their curative power to a common quality,
even that of diminishing general sensibility. The operation of some among
them, opium and belladonna, for instance, appears to be directly antago-
nistic. Leaving any criticism of principle, it is of more interest to know
that, as a physician. Dr. Reynolds has found all of these and some other

148

Ketiews.

[July

analo.s^ous medicines, including chloroform, palliatives and nothing more.
Bromide of potassium, oxide of zinc, ammonio-sulphate of copper, and
nitrate of silver, he has no confidence in, althouglr of the second he admits
that he cured one case by it, and that many were improved for a time. In
stating that "according to Herpin's own account of it, but little value can
be attached to its employment,'- there appears to be an error, since the
author referred to ranks it second of all the remedies that he tried. The
various bitter and metallic tonics are useful. Dr. R. believes, only in special
conditions of the general health, as iron when ansemia is present. Dr.
Radclilfe, perhaps looking too steadily at his theory of debility as the root
of epilepsy, expresses a more favourable opinion of tonics, but particularly
of the nutrient tonic cod-liver oil, and other oils, and is disposed to think
that "they may have some claim to be regarded as of special use, not only
in cases of epilepsy, but also in all other cases in which the brain and nerv-
ous system are in need of a tonic."

Counter-irritation finds no favour in Dr. Reynolds' eyes; nor does frugal
diet; and he regards the success of Heberden, Cheyne, and others by the
latter means as exceptional. Dr. Radclilfe expresses a similar opinion.
Moderate but not fatiguing exercise is recommended by both of these writers.
In sleeping the head should be raised, and the extremities should always be
kept warm.

The second object of treatment is "to improve, or maintain unimpaired
the mental health," and the whole may be summed up in this phrase, as
applicable to the mind as the body — exercise without fatigue. All mere
emotional excitements should be shunned, but whatever occupies and inte-
rests without exhausting is beneficial. In a few remarks upon the treatment
of the attacks, Dr. Reynolds furnishes some illustrative proof of the value
of arresting the progress of the aura by compression, and refers to the
occasional benefits of cauterization as used by other physicians.

On the whole, the impression left upon the reader's mind by the con-
cluding portion of this work will, perhaps, be one of disappointment; for,
after the clear and cogent demonstrations of the preceding divisions relative
to the pathological history of epilepsy, one cannot avoid anticipating an
equally satisfactory exposition of the cure. But the brevity of this portion
is perhaps not one of its least recommendations. There being little to say,
the author wisely said but little, but yet enough to show that there is no
specific for epilepsy, nor even any certain method of cure; that on the con-
trary, the disease will most frequently continue, although its violence may
be mitigated and its victim's life be rendered comparatively comfortable
by a due attention to the laws of health. A. S.

1862.]

Saurel and Roc hard, Naval Surgery.

149

Art. XIV. — Traite de Gliirurgie Navale. Par Louis Saurel, Chirur-
gien de la Marine, Professor agrege a la Faculte de Medecine de Mont-
pelier, Correspondant de la Societe de Chirurgie de Paris; Suivi d'un
resume de lecons sur la service chirurgical de la flotte. Par le Docteur
J. Rochard, Chirurgien en chef de la marine, Professor a PEcole de
medecine navale du port de Brest, Oflficier de la Legion d'honnenr.
Illustre de 186 planches intercalees dans le texte. 8vo., pp. 592, + 104.
J. B. Balliere et Fils. Paris, 1861.

Treatise on Naval Surgery. By Louis Saurel, Surgeon of the Navy, &c. ,
followed by a summary of lectures on the surgical service of the fleet.
By Doctor J. Rochard, Surgeon in Chief of the Navy, &c. &c. Paris,
1861.

The practical application of the principles and art of surgery to the
treatment of wounds and injuries and certain maladies when they occur on
board of ships of war constitutes naval surgery; and so the application of
the same principles in the management of wounds and certain diseases when
they occur in an army constitutes military surgery. The principles and art
of surgery, whether practised in ships of war, in an army in the field, or in
civil life, are the same. In an army and in a navy, the surgeon is often
forced to resort to measures and means in caring for his patients which
circumstances suggest ; but which are or should be always consistent,
nevertheless, with the broad principles taught in the schools.

The work of surgeon Saurel might be cited in evidence of the remark
just made. It is a very simple summary of the mode of treating the wounds
and injuries most frequently occurring on board ships of war, according to
received principles. And although he states the causes of contusions and
wounds and fractures — consisting chiefly in the unsteadiness of the ship,
which render men who climb the rigging liable to fall, and those on the
decks to be injured by the falling or tumbling about of various objects
which, even with every precaution, sometimes break loose from their fasten-
ings, in storms especially — he offers no suggestion to guide us in the man-
agement of cases which, from the constant motion of the ship, he declares
to be often very difficult. He tells us that the operation for the relief of
strangulated hernia may become necessary, even during the prevalence of a
gale ; but, although he declares it to be difficult for the surgeon and hazard-
ous to the patient, we look in vain for instructions upon the mode of securing
both patient and surgeon during the operation against the violent rolling
or pitching of the ship. He might have added that the use of a trephine
on the skull may be necessary while the motions of the vessel are so great
as to render locomotion upon the decks very inconvenient, if not difficult
and hazardous, even to people experienced upon the sea. But such opera-
tions have been and can be safely accomplished, even under such unfavour-
able circumstances, by fixing both patient and operator in such manner that
they will be simultaneously affected by the alternating movements of the
vessel.

Surgeon Saurel tells us that patients with fractures cannot be treated in
their hammocks, and that the iron bedsteads supplied to the ship's hospital,
in the French navy, are objectionable, because, being fixed to the deck, they

150

Reviews.

[July

partake of all the motions of the vessel. The nautical cot, used in the
British and American navies, answers tolerably well, provided that the
patient, with a fractured lower extremity, is dressed before the cot is hung
up where it is to swing. He urges that fractures occurring on board ship
should be reduced at once, and the permanent dressings be applied, because
the surgeon receives the patient immediately after the accident, before swell-
ing can occur. He also is of opinion that a double inclined plane is not
applicable to the treatment of any fracture of the thigh occurring on board
ship.

In the year 1853, a work entitled ''Naval Surgery, or Clinical Studies
of the Surgical Diseases most commonly observed on Board of Ships of
War, by Louis J. Saurel, D. M. M., &c.,"^ was published, and is referred
to in the publisher's preface as the first edition of the present volume,
which the author did not live to finish. Had he lived, it is probable he
would have given us his views on the points which have been ably discussed
in that part of the work for which we are indebted to Dr. Rochard.

The summary of the lectures on the surgical service of the fleet, by Dr.
Rochard, is valuable and suggestive.

The military marine, he says, is created for combat. That is its chief
mission, and to that end all the elements of its organization should tend.
The care of the wounded in time of war is among the most important of
the duties imposed upon naval surgeons, and is at the same time the most
diflScult. Afloat, as well as ashore, war has exigencies before which every-
thing must bend, and which often oppose insurmountable obstacles to the
accomplishment of their functions. Then they need as much resignation
as devotion, as much self-possession as experience, to rise to the height of
their mission.

The difficulties in the navy and the army are not the same. They consist
chiefly, after a battle, in the number of wounded, the extent of ground over
which they are scattered, and the insufficiency of the means of transportation ;
in the navy, on the contrary, it is the crowding which embarrasses surgical
service after a fight at sea. The position of the wounded sailor is better
than that of the soldier. He has no apprehension of remaining in the rear
and falling into the hands of the enemy; he is not obliged to submit to
long hours of anguish, waiting for assistance; he is always sure of shelter,
and, however murderous may be the contest, the number of surgeons and
resources on board are almost always sufficient to meet all demands ; but
these conditions, favourable as they are to the individual, are embarrassing
for the service. On land the number of wounded never incommode mani-
pulation ; afloat they necessarily trammel the surgeon's movements. In
the narrow space into which so many men and so much material are
crowded, the deficiency of space is a permanent difficulty. The combat, and
the injuries caused by the fire of the enemy, always bring a certain amount
of disorder, which is enhanced by the presence of the wounded. At all
hazards they must be promptly removed from the batteries which they en-
cumber. It is not a question of humanity only; their presence interferes
with the manoeuvres of the artillery, and produces a depressing effect on

' Chirurgie navale, ou etudes cTiniques sur les maladies chirurgicales que I'on
observe le plus communement k bord des batiments de guerre, par Louis J. Saiirel,
D. M. M., ex-chirurgien de 2e classe de la marine, membre de la Societe de Mede-
cine-pratique de Montpellier, etc. 8vo. pp. 312. J. B. Balliere. Paris, 1853.

1862.]

Sal'rel and Roc hard, Xaval Surgery.

151

the moral tone of their comrades. Whatever may be their number, they
should receive immediate care, and be put in a place of security, and on
beds of some kind, until the end of the action.

Three conditions are indispensable to attain this result : —

1. An easy way and convenient means of transporting them to the hold
or to the berth -deck.

2. A sufficient space for urgent operations and first dressings.

3. A locality sufficiently spacious to spread out mattresses to receive
them afterwards.

These conditions are readily obtained when the wounded are few, and
succeed each other at long intervals ; but such cases are exceptional. When
a fourth or a third of a crew. of from 600 to 1000 are wounded in the
course of a few hours, as has happened, it is very different.

The passing of wounded men below in sailing ships presents few difficul-
ties. In single decked ships the hold is shallow, and there is not much
space for the accommodation of wounded men during an action ; but vessels
of this class are not, generally speaking, liable to have a large proportion
of wounded. The large hatches of frigates and ships of the line facilitate
the transportation of the wounded, and on the berth-deck and orlop there
is usually abundant space for the spreading of mattresses. But in steamers
it is different. Although the hatches are numerous, they are comparatively
small. The engines and coal bunkers occupy so much space in the centre
of the vessel, that it is very difficult to make suitable provision for the
reception of wounded men in the hold. In illustration of these points
there are given diagrams of the plans of the holds and berth-decks of the
several classes of ships.

Ships at anchor attacking fortresses suffer comparatively little. Of
French frigates exposed to the fire of 116 pieces of cannon, distant four
cables length from San Juan d'Ulloa, the Iphigenie had 5 killed and 30
wounded, and the Tanger, Magador, and Sale suffered still less. At Pe-
tropaulowski the frigate Forte had but 8 wounded. On the ITth October
the French and English fleets before Sebastopol, at an average of seven
cables length distance, sustained the fire of 316 pieces, most of them of
large calibre, served by good gunners, for five hours, and at the end of the
action, the 24 French ships, 12 of which were of the line, had 30 killed and
181 wounded in all, and the English 44 killed and 266 wounded.

Under such circumstances the wounded come at long intervals. Inasmuch
as the batteries of one side only are engaged, the opposite affords space for
the withdrawal of the wounded from the guns in action.

When an engagement takes place under sail or steam, the batteries on
both sides must be kept clear, and the wounded must be taken below at
once:

In the exercise at quarters in time of peace, it requires at least four
minutes to pick up a man supposed to have been wounded near a gun, carry
him to a hatch, secure him to a cot, and pass him below. Then the ship
is tranquil, and every body preserves his self-possession. But it may be
supposed that amidst the smoke, din, and confusion of battle, it would
require a somewhat longer time to move a man seriously wounded. Now,
if only 50 men are wounded, and allowing four minutes to transport each
to the hold, three hours would be occupied in their transportation ; and
during all this time the guns are encumbered and the gunners cannot ma-
noeuvre their pieces without the chance of trampling upon their wounded

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comrades. And if the number should be increased throug-h the effects of
the newly contrived explosive projectiles, the condition is worse. Hence, it
seems indispensable that means should be devised of more rapidly removing
so bloody a spectacle from view of the combatants.

It is suggested that when it is probable a battle will be serious on board
of a steamer, two passages from the deck below should be established for
the wounded ; one forward, and another towards the stern of the vessel.

As means of transportation, a cot or frame, fitted by ropes and blocks in
a hatchway, so that it may be readily lowered with a wounded man strapped
to it, is proposed, but objected to because of the difficulty of guarding it
against extensive oscillations impressed upon it by the motions of the ship.
A battle-chair, so arranged that it may be lowered by a pulley, is also sug-
gested. But it is very questionable whether the arms of a strong man may
not afford a better and more expeditious means of transporting a wounded
man than any contrivance hitherto proposed.

As in steamers, generally speaking, the engine divides the forward from
the after part of the vessel, it becomes necessary, when two routes for the
conveyance of the wounded are established, that the surgical force should
be divided and posted at two points, the surgeon being at one and the
senior assistant in charge of the other, both well supplied with the neces-
sary instruments and appliances.

A place for the deposit of wounded men during action is difficult to find
in steamers. It is suggested, to meet the exigency, the bag-rack on the
lower deck should be constructed of iron bars, so arranged that mattresses
would be spread upon them, and then, on beating to quarters, the bags
should be stowed in any empty coal bunker.

Certain preliminary arrangements are to be made before battle. The
distribution of tourniquets in the tops, required by an English regulation,
may be dispensed with in steamers, for the reason that these vessels furl
their sails before going into action, and very few, if any, men are kept aloft.
But there should be garrots supplied to men at the guns. The writer of
this notice submits that an efficient instrument consists of a piece of wood,
five or six inches long, a half inch in diameter, turned with a slight rim at
either end, near one of which is attached, by a clove-hitch, a piece of roller
three feet and a half long, and two and a half inches wide, so that the stick
may be about fifteen inches from one extremity, and, of course, twenty-seven
from the other. This simple instrument is applied thus : the fillet is passed
around the thigh, or arm, as the case may be, drawn tightly, and tied about
six or seven inches from the stick ; the free ends, which are sufficiently long,
are employed for securing the stick after it has been used in twisting the
fillet to the degree of tightness necessary to arrest the hemorrhage. A fillet
or ligature passed round a limb may be made tight enough to stop the flow
of blood, by twisting with a stick ; but after this point is gained, one may
be very much at loss for means of preventing the band from untwisting the
instant the stick is abandoned ; the simple instrument just described, is
proposed to obviate the difficulty on this point.

Surgical dressings, &c., arranged in two boxes or trays, with suitable
divisions, should be deposited in the dispensary, ready to be taken to each
of the two appointed stations of the medical officers.

Dr. Kochard gives, in a note, in detail, the quantities of various articles
which raay be needed, on board of a ship of the line, whose complement is
1087 nien.

18C2.]

Saurel and Ro c hard, Naval Surgery.

153

Dressings prepared, on a first-rate ship of the line, on the eve of
battle : —

Apparatus for amputations, in-
cluding compresses, rollers,
&c., in the same number.

Bandages for fractures, differ-
ent splints, graduated com-
presses, &c.

Bandages for the hand and foot.

Bandages for the head.

Bandages for the chest and
shoulder.

Bandages for the abdomen and
pelvis.

For the arm .

" forearm

" thigh five
leg .
Thigh .
Leg

Forearm .
Bands for fingers
Slings for the heel
Splints for fingers

Pads I^^M^'Jl^^f

Bandages (Galen's)
Triangles
Chin-pieces
Slings for the chin .
Bandages for the body
Scarfs or bands
Cushions or pads for clavicle
Spica bandages
Triangular "
Square for the groin
Perineal or T .
Suspensories .

5
10

5
10
4
8
8
48
18
18

18
18
18
24
18
4
6
12
12
12
12

For external use, cases not specified, rollers, compresses, &c., in sufficient
quantities. Charpie opened, and in pledgets. Sponges. Waxed threads,
single and double. Rolls of adhesive plaster. Strips of diachylon, of
different sizes. Agaric. Resin, in powder, Garrots. Sharpened pins,
for sutures.

Each bandage is made in a separate parcel, and labelled ; those of the
same kind being placed together, in a compartment of the box or tray.

Ammonias liq.

For internal use, bottles of

Earthen vases of

In addition to the above-

Brandy.
Camphorag tinctura.
Ether, Chloroform.
Ferri-persulphas.
Laudanum, Vinegar.
Plumbi acetas.
Cerate.
Olive oil.

Plates and shells of tin 2

Goblets .4

Candles , . 2

Bucket filled with sand 1

Buckets " fresh water 2

Brooms and swabs 2

To these may be added two or three tin basins, and a half dozen towels.

The surgeon should take care that the steward, nurses and other attend-
ants are instructed, and that each one understands exactly the nature and
extent of services required of him, so that at the moment of need the work

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may be executed in a neat, orderly manner without loss of time, or confu-
sion of any kind.

When the order is given to assemble at quarters the drum-beat gives the
signal.

On board Ficnch ships the first care is to evacuate the hospital, and have
those patients who are confined to bed conveyed below, and those not capa-
ble of performing duty at the guns are to be stationed in the hold to assist
their wounded comrades, by supplying them with water to meet the demands
of traumatic thirst, which is terrible in cases accompanied by great loss of
blood.

In sailing ships of the line, after the hospital has been cleared, the second
and fourth surgeons, aided by the officers' servants, spread mattresses and
covers proportioned in number to probable exigencies. The chief and third
surgeons set up and arrange the operating table in the hold, and make sure
that buckets of sand and fresh water and swabs are at hand.

In steamers, the principal post occupied by the chief and third surgeons
should contain the operating table, and instruments and dressings placed
so as to be at hand. A weak mixture of wine and water in sufficient quan-
tities, with goblets for the use of the wounded ; buckets of water, sand, and
swabs should be provided, and everything secured against the motions of
the ship. The chief surgeon should also take care that there is sufficient
light supplied by lamps, lanterns, &c.

The station of the second surgeon, at the opposite end of the ship, is to
be provided and prepared in like manner.

Having seen that all his orders have been executed, the chief surgeon
then descends to his post, which he is not to leave, except by express order
.of the commander of the ship.

At the moment when firing is about to commence a profound calm reigns
throughout the ship. Motionless expectation succeeds the tumult which
immediately followed the drum-beat to quarters, and silence takes the place
of noise. The moment is serious. Every one feels a necessity of collecting
himself, and memory is busy with the past. The first broadside cuts short
reflection, and every one thinks only of his duty. That of the surgeon is
not the least painful. The emotions of the combat, and the excitement
attending success, are equally unknown to him. He is ignorant of what is
transpiring on deck. He judges of the greatness of the contest only by the
horrors of its results ; he cannot conjecture the issue. Bent beneath the
beams in his narrow retreat, where the want of air, space, and light are
simultaneously experienced, seeking by doubtful illumination in a stifling
atmosphere to extract a projectile or to cast a ligature about an open vessel ;
sometimes overborne by the rapidity with which the wounded succeed each
other, he must preserve, amidst the scene of carnage, the self-possession of
the physician and the calm of the chief of his department. The execution
of these austere duties is not always exempt from peril. Surgeons are
classed as non-combatants in the division of the advantages which inure to
success of the fight, though they do not always escape death.

If, says Dr. Rochard, the navy should be called upon one day to renew
the grand contests of past times, the means of destruction are now such as
to equalize the chances of all, and where there is an equality of danger
there should be an equality of glory.

Operations requiring much time are rarely necessary during the engage-
ment, and indeed it would be imprudent to attempt them. The surgeon's

1862.]

Saurel aod Rochard, Naval Surgery.

155

attention is to be given to urgent cases, and to the dressing of slight ones,
that they may return to the deck. After the firing has ceased, he has to
coDQplete his labours, attend carefully to every case, and arrange his hos-
pital.

The question of amputation under different circumstances of injury is
judiciously discussed. He concludes that in compound and complicated
fractures amputation should be the exception and not the rule of practice.

If after a battle, while the decks are occupied by many wounded, bad
weather should supervene, and require the closing of the ports, we may
expect from humidity, and a vitiated atmosphere consequent upon reducing
the means of ventilation, unfortunate complications. The danger augments
with the number of wounded. To the ordinary causes of the vitiation of the
atmosphere are added the emanations from extensive suppurating wounds,
some of them complicated with gangrene.

Deficiency of air, humidity, and miasms are three foes to the surgeon's
efforts which must be guarded against. If the weather is fine and dry, and
the ports can be kept open, there is little to fear ; ventilation takes care of
itself, and guarantees salubrity. Under opposite circumstances precaution
is indispensable, and sometimes no degree of care is enough to avert the
danger.

It is to be hoped that some system of ventilation for ships may be devised
which will afford a ready means of furnishing abundant supplies of fresh air
to the most profound and remote points of their structure. A forced ven-
tilation in steamers ought not to be difficult to accomplish, and at a cost
of very little power. In the absence of such contrivance, wind-sails and
drying-stoves must be substituted. The former should be at every hatch,
and fires in the latter should be constantly lighted and distributed at regular
intervals among the beds; and beneath those from which the most ofi'ensive
smells emanate broad vessels containing chloride of lime, slightly moistened,
should be placed.

The maintenance of an unexceptionable degree of cleanliness is most
important ; but care should be taken that it be not attained at the cost of
profuse and frequent washings. These should be proscribed when the
weather is damp, or when the ports are closed. The broom and dry holy-
stone should suffice for general cleaning, with the application of a domip
swab to very dirty spots. And at all times hot fresh water, rendered
slightly alkaline by an admixture of wood-ashes from the galley fires, is to
be preferred while wounded men are on the decks. As a means of lessening
the necessity of washing, canvas cloths might be spread between and around
the beds during meals, for the purpose of receiving and removing imme-
diately after, scraps of food dropped.

Dressings should be renewed twice daily, and parts of apparatus should
be changed whenever they become imbued with liquids discharged from
wounds. Small pieces of dressings, charpie, &c., when removed, should be
at once thrown overboard, and large bandages, compresses, &c., should be
immersed in buckets of sea-water and speedily removed to the place desig-
nated for washing them in fresh water. Wounds should remain exposed to
the air no longer than is absolutely necessary to dress them. When the
wounded are detained on board during a considerable period, whitewash,
containing a little hypochlorite of lime, should be applied to the neighbour-
ing wood-work from time to time.

Do what we may, any considerable number of sick on the lower decks of

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[July

a ship is never free from danger. The roost serious cases should be allocated
in the most airy situations, and those capable of locomotion should be
required to pass the greater part of the day on the spar deck, when the
weather is favourable. Exposure to the open air, the vivifying influence
of sunlight, sight of their comrades, and the change of scene produce the
happiest effects upon their moral and physical condition, while their al)sence
from the sick-quarters diminishes the crowding. On the other hand, in
high latitudes, it may be necessary to send these cases to the berth-deck to
shelter them from the cold, and from currents of chilling air. After the
affair at Petropaulowski the French division went north, and four of the
wounded, from the cold of the nights especially, w^ere attacked with tetanus
and died. Xo cases occurred after the wounded were removed to the berth-
deck.

The diet of the w^ounded should receive particular attention. After a
naval engagement the conditions in which they are placed are debilitating,
and therefore a substantial and reparative regimen is the best calculated to
protect them against threatened complications.

A chapter is devoted to the consideration of the preparations necessary
to be made by the medical officers who accompany boat expeditions and
parties landing to attack strongholds on shore. There should be provided
a strong tin case, covered with leather, of the dimensions and form of a
knapsack, with drawers and compartments, to contain surgical instruments,
some short splints, lint, sponges, rollers, adhesive plaster, simple cerate,
thread, sewing needles, dressing pins, wax, sulphate of quinia divided into
powders or pills, a glass cup, a tin or leather goblet, candle and candlestick,
laudanum, ammonia, vinegar, tincture of camphor, brandy, &c. The
liquids should be in strong glass bottles, each one packed in a separate
drawer. This case may be strapped upon the back of an attendant who
accompanies the march. The surgeon's position in the field may be marked
by a yellow flag, and the hospital boat, or ship, as the extent of the expe-
dition may suggest, may be designated in the same manner.

It is w^ell to provide litters for the transportation of the wounded. Two
shafts or poles, about the length of a boat-hook, ferruled at the extremities,
one of which may be sharp, like a boarding-pike, and serve to repel enemies
in case of need, having a piece of canvas, about six feet long and two and
a half wide, fitted so that it may be attached to the poles by grummets, are
readily converted into a litter, with the assistance of a couple of stretchers.
In an extemporized litter of the kind a wounded man may be carried easily
by four men, or even by two. If obtainable, the shafts may be made of
stout bamboos, w^hich are strong and comparatively light.

We have many valuable suggestions in this chapter, and interesting no-
tices of several boat expeditions in which the French have been engaged or
taken part. But enough has been said to indicate the nature and scope of
the volume which we cheerfully commend to the younger medical officers of
the navy. W. S. W. R.

1862.] DoBELL, Germs and Yestiges of Disease. 15Y

Art. XY. — Lecfinr^s on the Germs and Vestiges of Disease, and on the
Prevention of the Invasion and Fatality of Disease by Periodical
Examinations. Delivered at the Royal Intirmary for Diseases of the
Chest. By Horace Dobell, M. D., &c. &c., Physician to the Infirmary.
London: 1861. 8vo. pp. 198.

A TRULY philosophical endeavour to analyze the facts of medical expe-
rience should always be welcomed by the profession. It is no unwillingness
to reason, or want of confidence in the value of careful ratiocination, that
induces many of the best medical minds of the present time to rank them-
selves, as therapeutists, under the banner of methodical empiricism. Not
all going so far in opposition to rationalism as to believe with Trous-
seau that this necessarily "ne conduit qu'a des sottises," they must, upon
the very basis of induction, admit and honour all efforts towards the
classification and generalization of medical facts. Of the results of such
efforts, however, there has been a lamentable deficiency in the science and
literature of practical medicine. The natural history of disease has been
but vaguely studied, and taught according to routine and dogma. The
want of a sound medical philosophy, or even philosophical method of study
in medicine, is thus, to speak boldly, hardly better met than in the days of
Celsus or Aretseus. We believe it to be impossible to apply at present,
upon any extended scale, the recognized truths of physiology to the imme-
diate purposes of the physician in the treatment of disease; but the biolo-
gical or naturalistic method of investigation of the facts both of morbid
or perturbed physiology, and of therapeutical experience, must be approved,
and should be adopted.

It is for the apparent honesty of his effort in this direction, quite as much
as for the degree of his success therein, that the work of Dr. Dobell appears
to us to be entitled to very attentive and respectful consideration. His
subject is one which must interest every thoughtful physician. The occa-
sion of its having occupied his mind so far as to lead to the preparation of
this work, may be best understood from his own statement : —

" "When I commenced private practice, I had devoted more time to the study
of medicine in hospitals and medical schools than most students have at their
disposal; in addition to which I had read nearly every medical and surgical
work of good repute, ancient and modern. And I naturally expected to find
myself quite at home with any cases which might present themselves in private
practice. To my surprise and disappointment, however, I found myself sur-
rounded by complaints which appeared quite strange to me, and I kept vainly
hoping that each new case might he placed under one of the well-known head-
ing so familiar to me in the hospital-ward, the out-patient room, the book, or the
lecture theatre, and the management of which I had so carefully learnt.

" Cases of pneumonia, apoplexy, variola, fever, or the like, were positively
refreshing, when, from time to time, they came in their well-known features. But
these were few and far between ; whereas I found the principal part of my time
occupied with diseases or states of health for which I could find no special
names, and for which I had learnt no plans of treatment."

"Many years after the period to which I refer, an article appeared in the
Times newspaper, just at the time that I was engaged in making notes for these
lectures, which appeared to be so apposite that I placed it with my notes, as full
of interest and meaning."

158

PvEYIEWS.

[July

The following is part of the article referred to : —

"What is it that is worse than a sweatino; sickness, or a plague, which comes
with a bale of Turkish goods, and goes with a great fire, which wears itself out,
and leaves no record but in story, which old men may describe to wondering
grandchildren, and which doctors may now set down as an individual and extinct
type-of disease? It is not disease, hut it is not health. It is a low state of vitality,
of physical power, of mental energy, of eDj'oyment. and even of moral strength.
.... Shocking as it may seem, a plague once in twenty years seems but a light
evil to so low a condition of humanity."

" These remarks are directed chiefly to the very poor : but it is not they alone
who suffer from states of health here so forcibly portrayed. Many of the con-
ditions of low health, and of anomalous disease to which I have referred, are more
frequent among the well-oflF than among the poor." (pp. 30-32.)

The plan of the author involves a scrutiny of the very foundations of the
theory and practice of medicine. His first lecture opens with the announce-
ment of a medical creed, in the following terms : 1, That man may be the
instrument through whom the invasion and progress of premature destruc-
tive changes in the human organism may be prevented or arrested. 2. That
man may be the instrument through whom the damaged organism may be
more efficiently repaired. 3. That man may be the instrument through
whom the sufferings of the human being may be alleviated. The justifica-
tion of medical practice requiring a belief in these articles, it is rightly
considered that their truth should be first well established as the basis of
any system of therapeutical doctrine.

The third article is too familiarly attested to need much remark. The
first and second, concerning the aid man may give in promoting the repair
or preventing the destruction of the organism, must be considered in view
of the results of investigation of the capacity of the organisrn itaelf to
effect these ends icithout the instrumentaiity of man. This investigation
must be prior, in a logical sense at least, to therapeutical experimentation.
Dr. Dobell, therefore, gives it his first attention ; occupying with it the
whole of the first two lectures.

Facts in comparative physiology are brought to bear upon the laws of
production, repair, and reproduction of the human organism. The greater
portion of these facts is collected by our author in an appendix ; where the
reader may study at length numerous examples, from all divisions of the
animal kingdom, of spontaneous recuperative power.

The general law which the author thinks himself justified in inditcing
from these well authenticated examples, is thus expressed: "At every period
of an animal's life, the force manifested in production, maintenance, growth
and repair, and reproduction, is sufficient in every respect, and determined
in that direction, essential at the time to the attainment of the ultimatum.''^
The term ultimatum here means merely the consummation of the design
with which the animal appears to have been formed. In the insect, neither
the larva nor the pupa has attained the ultimatum ; nor can the imago be
considered to have done so, until it has secured the multiplication of the
species, in the fecundation of the necessary number of ova. In man, the
ultimatum of existence is not bounded by the same limitation, but includes
still higher functions.

The point of especial interest in the application of this law is the deter-
mination of force at each epoch of the animal's career, in that direction
essential at the time to the attainment of the ultimatum. The individual
is, however, throughout the animal kingdom, subservient to the species;
and our idea of the ultimatum must be extended to the species. If the

1862.]

DoBELL, Germs and Yestiges of Disease.

159

career of an individual of any species be cut short, it does not necessarily
follow that the law for the attainment of the ultimatum has been violated.

The determination of reproductive and reparative force to the restoration
of that part the permanence of which at a particular time is a condition
of the animal's existence, and which is, by the circumstances of its life at
that time, most subject to injury, is beautifully illustrated in Hydriformia,
Asteriae, and Cirripedia. Dr. Dobell quotes the following from Darwin : —

"In cirripeds, the larvge in the first stage have three pairs of legs, a very sim-
ple single eye, and a probosciformed mouth, with which they feed largely, for
they increase much in size. In the second stage, answering to the chrysalis
stage of butterflies, they have six pairs of beautifully constructed natatory legs,
a pair of magnificent compound eyes, and extremely complex antennae, but they
have a closed and imperfect mouth and cannot feed; their function at this stage
is to search by their well-developed organs of sense, and to reach by their active
powers of swimming, a proper place on which to become attached and to un-
dergo their final metamorphosis. When this is completed they are fixed for
life. Their legs are now converted into prehensile organs, they again obtain a
well-constructed mouth, but they have no antennae, and their two eyes are now
converted into a minute, single, and very simple eye-spot."

Among vertebrated animals, the power of reproducing lost limbs is be-
stowed most largely upon the salamander, an animal of predatory habits,
and living among carnivorous feeders. In the land lizard, the tail is at
once a means by which it is apt to be captured, and its instrument in eluding
its pursuers; and a power to disengage it from itself is coupled with an
extraordinary facility in reproducing the lost part. The fish requires the
persistence of the fins as a condition of its existence, and they are pecu-
liarly exposed to injury, from constant use and from the attacks of enemies;
the power of repair is, accordingly, especially determined to them.

Now, what, in man, is the special direction in which reproductive and
reparative energy is determined? After birth, at least, there is no instance
on record of even an attempt at the restoration of a lost human limb ;
although supernumerary fingers have sometimes been reproduced after re-
moval. But Dr. Dobell insists that this non-reproduction of limbs comes
from no want of the force necessary to restore them, if it were a condition
of our existence that they should be so reproduced. The occasional re-
formation of a whole bone, and the cases reported by Dr. Simpson of the
renewal, although imperfect, of limbs spontaneously amputated in the foetus
in utero, testify to the. existence of this capacity, latent, as it were, in the
higher vertebrata.

The study of the conditions of existence of the highest animals, will
inform us of the direction in which reproductive energy is exhibited in them.
As -we ascend the scale, we find most remarkable advances in the develop-
ment of intelligence, and in the complexity and delicacy with which organs
are correlated. By reason of the former, man is much less dependent than
the lower animals upon the possession of his external members.

With increased complexity and delicacy in the correlation of organs,
comes a proportionate increase in the importance and difficulty of keeping
them repaired. The influence of a highly and delicately organized nervous
apparatus upon susceptibility to disease is illustrated to some extent even
in the domestic animals; although much more largely in man.

It may be properly urged, then, that in man, a continual reproduction is
going on, of those parts most necessary to the conditions of his existence,
or "the necessities of the ultimatum." This is seen in the formation and
re-formation of blood-corpuscles, of the secreting cells of glands, and of

160

Reyietts.

[July

cuticular epithelium. The alterations in the size and activity of blood-
vessels following upon obstruction or injury; the increase in the number of
fibres of the muscular tissue of the heart or bladder when extraordinary
resistance is to be surmounted; the occurrence of vicarious secretion, and
other examples, are dilated upon by our author, as showing how the vital
energy in man is especially determined towards the presermtion of cam-
pleteness in the complex correlations of his organism, amidst the no less
complicated dangei's by which it is surrounded. Paget is quoted as con-
firming this view by the statement given by him of the limits of reproduc-
tive powder in man and other mammalia. These include only "the blood
and epithelium," "the gelatinous tissues, cellular and tendinous tissues and
bones," and "those which are inserted in other tissues, not as essential to
their structure, but as accessories, as connecting or incorporating them with
the other structures of vegetative or animal life; such as nerve-fibres and
bloodvessels." All of these are important to those correlations of organs
which have been alluded to. As Dr. Dobell remarks, the organs which
cannot be so perfectly restored are either such as are seldom entirely removed
without the death of the individual, or such as are provided with duplicates
endowed with the power to assume a complemental function, or such as are
competent in themselves to compensate for loss of a part by augmenting
the functions of the remainder.

Beyond this, however, the human organism is also subjected to dangers
other than those included in solutions of continuity ; hj poisons, organic
and inorganic, and by the whole army of influences commonly classed as
causes of disease. To what extent, it becomes necessary to ask, is the
animal body capable of preventing the invasion and resisting the pi'ogress
of premature destructive changes, without the intervention of man? The
simplest example of this is afforded in the introduction of an inorganic
poison, as arsenic.

Arsenic and other poisons are disposed of, so as not to be injurious, as
we know that a poisonous dose may be given with impunity, if divided into
several parts and given at certain intervals. How, and within what limits,
then, is it, that the organism disposes of poisons, for its protection against
their power ?

This forms the first subject of Dr. DobelPs second lecture. The method
of disposal of poisons introduced into the economy is best understood by
reference to the normal excretory processes. These remove substances
which, if remaining, would prove essentially poisonous. Dr. Richardson
has illustrated this in his experiments upon the injection of lactic acid into
the peritoneal cavity of animals. The balance of excretion and secretion,
with nutrition, is indispensable to health.

"When, however, this balance is disturbed, some matter essential to the con-
stitution of some other matter becomes deficient, or some matter collects in
undue quantity, and, in either case, other organs and functions than those prima-
rily involved are drawn into the service of the organism, to restore, if possible,
the balance thus disturbed. And when we bear in mind the important fact that
the normal constitution of any one part is dependent on the normal constitution
of all the rest, w^e shall at once see how easily imperfectly formed elements of
nutrition may be generated in the organism, with all the features which we are
accustomed to recognize as disease. How complicated may the processes
become! How complex the outward manifestations! Or, again, how simple !
For all -that may attract the physician's observation may be tlie last scene, suc-
cessful or unsuccessful, in the attempt to get rid of a redundance or to supply a
want." (p. 25.)

1862.]

DoBELL, Germs and Vestiges of Disease.

161

As to the limits within which vital energy, or, as our author prefers to
call it, the "vitalized mode of force," can act successfully in asTesting the
destruction of the organism, no rule can be definitely laid down which will
apply to individuals. It must be admitted that the human being may, un-
aided, live through injury, through disease, through almost anything, under
favourable circumstances.

These last three words confer, or constitute, to use our own words, the
physician's license to practice. How seldom are the circumstances abso-
lutely and perfectly favourable ! If they were, our vocation would indeed
be a sinecure. Not being so, the manifold and most important influences
of circumstances upon the manifestations of vital energy must be carefully
studied, to afford answers to the great although simple questions, what is
there for the medical practitioner to do, and how ought he to do it?

Dr. Dobell asserts here the very important proposition, "that the vital-
ized mode of force may be altered in its attributes of quantity and quality
by numerous causes." This involves a discussion, succinctly gone into by
the author, of the doctrine of force, and the correlation of physical and vital
forces, as modes of motion, expounded by Grove, Carpenter, and others. As
all the knowledge we have of different modes of force is inseparably con-
nected with different modes of matter, it is concluded that the "necessary
concurrent modes of matter" are, as regards force, the "conditions of its
existence." Changes in the modes of matter connected with vital force
must subject it to changes in its attributes or manifestations.

The view maintained by so many physiologists, that the amount of vital
force with which each individual organism is endowed is a limited quantity,
a portion of which is "expended" in development, growth, and maintenance,
so that "reparative power bears an inverse ratio to the amount of force
already consumed in these processes," is contradicted by our author. Let
us give his ground of opposition to it the benefit of his own statement.

"According to the most recent statistics employed by actuaries, it may be
calculated, that out of every 100,000 children bom. only 63,296 reach the age
of twenty-five years ; 36,704 dying from various causes before that age. If each
of these 63,296 individuals has, at the age of twenty-five, produced one child aud
y\ths, the number thus obtained will be only a fraction more than is sufficient
to compensate for loss, and to bring the population up to the original quantity.
In order, then, to keep up the population, the vitalized mode of force with which
each individual was endowed at birth must have accumulated at least y'^tus
during life, instead of wasting, expending, or being consumed ; otherwise,"the
individuals of each successive generation would be endowed with a smaller quan-
tity of force than their predecessors. And as, so far from the population being
only maintained at a fixed quantity, it increases at a great rate, the accumulation
of vital mode of force must be proportionably great, to fulfil this necessity of
org'a-nic existence, we discern — or at least such is my hypothesis — that every
living thing is given, 1st, a certain endoioment of vitalized mode of force, with
which to begin its career ; 2dly, accumidators of fresh force, the amount which
it can thus accumulate being regulated only, c ceteris paribus, hj the require-
ments of the ultimatum." (p. 42.)

No question in biology is more interesting, aud perhaps none more ex-
tensive in its bearings, than that which is thus opened before us. It would
be quite impossible to do justice to its consideration within our limits. We
must say, however, that the hypothesis abovestated appears to us tobeentirely
gratuitous. It may be readily granted that there is no evidence anywhere
of the annihilation of force, any more than of matter ; that what is, or
should be, meant by such expressions as loss, expenditure, or consumption
No. LXXXYIL— July 1862. 11

162

Reviews.

[July

of force, is merely the determination of force into other modes or directions*
i. e., its conversion or devolution into other kinds of force. But, in this
sense, we know that there is a limitation to every special impulse in the
dynamics of nature. We know that all terrestrial life, in each individual,
tends to certain death, at or near a definite period. "We believe that the
only ascertained accumulator of vital energy belongs not to the individual,
but more properly to the species ; being the conjugation of the sexes, the
union of the sperm-cell and the germ-cell. This view requires the admis-
sion of the truth of Carpenter's assertion, that ''between generation and
development (including budding) there would seem to be a kind of anta-
gonism. Whilst every act of development tends to diminish the germinal
capacity, the act of generation renews it."

But this does not prevent the conditions of life, or "concurrent modes of
matter," from exerting a marked influence upon reproduction and its results,
as well as upon individual vital energy. Dr. Dobell's hypothesis is not
necessary to his own conclusions. He remarks, very truly, that Darwin has
not, in putting forward his theory of "natural selection," done full justice
to the "conditions of existence," as affecting both the individual and the
species. There is no difficulty in assenting to our author's conclusions upon
the subject at which we have been glancing, as follows : —

"That the vitalized mode of force may be altered in quantity and quality by
numerous causes.

"That these causes may affect either the existing individual, a succeeding
generation, or both.

"That these causes are, prindpalli/, the vestiges of disease, existing or coeta-
neons diseases, and the conditions of life.''

"The effects of injury or disease and the manifestation of the vitalized mode
of force in protecting, restoring, or repairing the organism, depend upon the
relation which exists at the time between the following conditions : —

"a. The position of the animal and of the part affected, at the time, with
respect to ttie attainment of the ultimatum.

",3. The state of the part affected, and of all correlated parts.

"y. The state of the conditions of life at the time.

"§. The quantitative and qualitative state of the vitalized mode of force."
(pp. 47-8.)

We are thus brought to the more practical part of the volume; which
introduces the study of the vestiges and germs, or the "wells and springs"
of disease, by an animated account of "a day's practice." A number of
chronic cases, and a few acute ones, are described, to illustrate the connec-
tion of the occurrence, severity and mortality of diseases with the previous
medical and hygienic biography of the individual. Here we begin to be
somewhat painfully reminded of the great gulfs of difficulty which pathology
presents, and which no theor}^, or, so far, induction has been able to bridge
over with other than merely temporary structures. The first case, very
graphically narrated, is one of nervous disorder; in which the diagnosis is
nmde, that the patient is "saturated with the poison of rheumatism." The
second is that of a corpulent old lady, "teazed to death with erysipelas,"
or rather eczema, of the ears and sides of the head, with other complaints.
A strict examination leads to the "discovery that she is saturated with the
poison of gout, or rheumatism, most probably gout, which is acting as the
germ of several forms of disease."

Now,, what is rheumatism, and what is gout? And what is that poison,
or what are those poisons, with which these patients were saturated? How
that most probably^ ^ interferes with the eqiianimity of our self-gratulating

1862.]

Dob ELL, Germs and Yestiges of Disease.

163

inductive medical philosophy! Probably enough, the diagnosis may be
correct; although it does not follow so necessarily from the symptoms
related as our author's confident expressions might seem to indicate. And,
with gv%2it prohahility, we may believe that, in the one case, the poison is
lactic, and in the other uric acid. But a doubt remains, which is of serious
moment to our ratio medendi.

It would be extremely difficult to do justice, in a few words, to the re-
mainder of Dr. Dobell's work, which has been carefully thought out, and
closely written, so as scarcely to bear further condensation. We commend
it to the study of the reader, as containing suggestions, and evolving prin-
ciples, which, however they may have been before presented, are here elabo-
rated, in a manner well adapted to favour their proper appreciation. The
immediate purpose of the remaining lectures is to show how the vestiges
of one disease become, in very many cases, the essential antecedents, the
predisposing antecedents, or the causes of fatality, in other diseases. This
is done by a careful and tabulated etiological analysis of typhus and typhoid
fever, apoplexy, paralysis, heart disease, pericarditis, rheumatism, gout,
bronchitis, atrophy, and debility. The statistics of the Registrar-General's
reports are skilfully made nse of, and the very extensive and important
interdependence of diseases is satisfactorily demonstrated. A similar exhi-
bition is then made of the importance of anaemia, of syphilis, and of fatty
degeneration, as vestiges, and as frequently unrecognized germs of disease,
and causes of deaths registered under quite different names.

A single example of the first of these series of analyses may suffice to
illustrate their nature.

Vestiges of one or more attacks
OF Gout.

Predisposing antece-
dents to.

Essential antece-
dents to.

Causes op fatalitt

IN.

Deposits of urate of soda in
and about joints and some
other parts.

Tendency to a return of the
attack in the parts pre-
viously affected.

Anaemia and nervous ex-
haustion, especially from
repeated attacks.

Apoplexy.

Attacks of Gout.

Bronchitis, rheum-
atic and gouty at-
tacks, typhus.

Heart diseases.

Atrophy and de-
bility, and do.
in offspring.

Bronchitis, rheu-
matism & gout,
typhus, heart
disease.

The following passage from Dr. Dobell's last chapter will convey very
succinctly his conclusions, and his view of their practical bearing: —

"We have plainly seen that the organism is competent to take care of itself,
provided that it possesses a normal vital energy, ' and is surrounded by normal
conditions of life ; and we have also seen that the great causes of defect in the
vital energy are, the vestiges of disease and abnormal conditions of life ; and
we have also learned that the diseases, from which the vestiges result, are invited,
by defects of the vital energy ; and that when thus invited and received into
the organism, they are capable of being disposed of without leaving vestiges
behind, if the vital energy is free from excessive defect ; that thus these vestiges
are due to defective vital energy. And as we have learned that the earliest
invasion of defects in the vital energy, upon which all the long and intricate
succession of ills depend as their germ — as we have learned, I say, that this
state of germination exists at a period anterior to the manifestation of disease

Designated in the work by the symbol V. M. F., or ^'vitalized mode of force.^''

164

Reviews.

[July

in its ordinary characters, and that it is to be found in the garb of slight impair-
ments of the general health, the indications of which are more and more evasive
and occult, the earlier the stage of germination ; and, finally, as we have learned
that it is in this occult and evasive stage of germination that the defect is most
easily and most efficiently to he remedied ; I think you will agree with me in the
practical conclusion at which I have arrived.

" That the manner in which man is to exercise his instrumentality for the pre-
vention of disease, the prevention of the vestiges of disease, and the prevention
of fatality in disease, is to search out these earliest evasive periods of defect in
the physiological state, and to adopt measures for their remedy. This appears
to me to be the highest, the most ennobled duty of the physician, calling for the
most abstruse knowledge of the science of life, the deepest experience in disease,
the keenest exercise of the perceptive faculties, the calmest, most far-sighted
reasoning, and the wisest judgment — a duty as much above the management of
acute disease as to rule an empire is above fighting a pitched battle." (p. 153.)

Dr. Dobell then proposes to anticipate, in individual cases, the develop-
ment or germination of morbid conditions, by instituting, as a custom, a
system of periodical examination, to tvhich all persons should submit
themselves, and to which they should submit their children. Having no
occasion to doubt that this would be an immense benefit to the public, a
little more consideration is necessary to enable us to see how it would affect
the profession.

In order to maintain the interests of medical men, however, under such
a system, it would only require to establish such a scale of remuneration
for these thorough scientific examinations, as would correspond with their
value to patients in economy of health and in lessening the probable need
of much intermediate attendance. Of course, the poor should be provided
for in this arrangement, by the formation of special departments in all hos-
pitals or dispensaries, for the purpose; whereby, as our author urges, a
great saving of medicine, now expended in mere temporary relief, might
be attained.

We believe that this project, novel as it may seem, affords much pro-
bability of usefulness. The difficulty of securing its general introduction
will, it is likely, be greater with those who are most to be benefited,
namely, the public at large, than with physicians. Many, who are ex-
cessively anxious about obvious symptoms of disease, prefer to remain
obstinately blind to remote dangers or latent evils. It may be very hard
to convince these of the value of a preventive examination while they are
in tolerable health, or to persuade them to the use of precautions, however
timely, which may involve some trouble or self-denial. On the other hand,
the medical man, too often tantalized by uncertainties of prognosis, and
difficulties of treatment, growing out of the "defective vital energy" and
"conditions of life" of his patients, may be gratified to find opportunities
for the exercise of his skill and judgment, where certain and favourable
results may be almost calculated upon, and where death is not continually
knocking at the door. The proposal of Dr. Dobell, then, even if it should
not meet with immediate acceptance, is one of so reasonable a character,
as to deserve consideration. The thanks of the profession are due, more-
over, to its author, for a work, so full of careful and laborious thought,
based directly upon assiduous observation, as to constitute an important
contribution to scientific medicine. H. H.

1862.]

165

BIBLIOGRAPHICAL NOTICES.

Art. XYI. — Reports of American Institutions for the Insane.

1. Of the Butler Hospital, for the year 1860.

2. Of the New Jersey State Hospital, for the year 1860.

3. Of the Western Asylum of Virginia, for the fiscal year 1859-60.

4. Of the State Asylum of South Carolina, for the year 1860.

5. Of the Northern Ohio Asylum, for the fiscal year 1859-60.

6. Of the Hamilton County [Ohio) Asylum, for the fiscal year 1858-59.

7. Of the Asylum of California, for the year 1858.

8. Of the Wisconsin State Hospital, for the year 1860.

1. The principal numerical records of the Butler Hospital for the year 1860,
are as follows : —

Men. Women. Total.

Patients at the beginning of the year . .68 67 135

Admitted in course of the year . . . .33 25 58

Whole number 101 92 193

Discharged, including deaths .... 33 33 66

Remaining at the end of the year ... 68 59 127

Of those discharged, there were cured . . 22

Died . 15

" The deaths include but two cases of recent attack. The rest were of per-
sons who had been insane for a considerable period. Among them were four
women, aged, respectively, 71, 77, 78, and 93."

The publication before us contains one of those interesting monographic
essays for which the reports of Dr. Ray have become remarkable. The subject
treated is, as nearly as can well be expressed, the suppression of a hereditary
tendency to insanity. We shall attempt, by a great abridgment from the ori-
ginal, to impart a general view of the whole essay.

" The hereditary character of insanity is a fact as firmly established as that
of the propagation of certain other diseases by contagion. And, unquestiona-
bly, of all the agencies concerned in the production of insanity, this is the most
prolific. ^ *

• " The organic law in question does not imply the transmission of actual dis-
ease, but of tendencies to disease ; nor is it always in the line of direct descent,
nor with any regulated degree of intensity. It may skip over, so to speak, a
whole generation, and make its appearance in the next. It maybe traced back
to its source, not through parents, but through uncles and aunts. It may be
overt and unmistakable insanity in the child, and eccentricity or strong pecu-
liarity in the parent ; and vice versa. The tendency may be transmitted irre-
spective of other parental qualities ; and the child who bears the features
exclusively of the father, may inherit the mother's tendency to disease. It may
strike down its victim in the freshness and vigour of youth ; it may wait until
the mind has stood many a shock, and encountered many a trial.

The case, however, is one of not unmingled discouragement. Here, as
everywhere else, nature mitigates the severity of its laws by compensatory
arrangements. The organic condition on which the tendency depends is not
invariably transmitted to every child, any more than certain traits of body or
mind ; or, if transmitted, is endued with so little activity and power as to
remain dormant, and become extinguished in the next generation by the over-
powering tendencies of a different blood. And even when transmitted in a state
of considerable energy, it may often be kept in abeyance by a course of bodily

166

Bibliographical IN'otices.

[July

and mental discipline specially ordered for this purpose. * * * There is
reason to believe that many persons, thus unhappily constituted, have warded
off an attack of disease, by looliin^ the evil firmly in the face, and resolutely
shunning, in their diet, regimen, habits, occupations and amusements, mental
and bodily exercises of every description, whatever might be supposed likely to
produce unhealthy excitement.

" The first consideration I would urge on this class of persons, is, that a ten-
dency to mental disease is liable to be increased by any derangement of the
bodily health. * * * Parents who have reason to fear the existence of here-
ditary mental infirmities in their offspring, have an additional inducement to
watch over their health, to strengthen their bodily powers, and promote a happy
balance of the various faculties of the mind. * *

"Although insanity seldom makes its appearance in childhood, yet it can
hardly be doubted that the initiatory step is often taken at this period towards
the development of morbid tendencies. * * In the physical education of
this description of children, it should be a prominent object to strengthen the
nervous system. ^ * ^ Much sedentary employment, much confinement
to warm rooms, sleeping on feathers — all improper enough under any circum-
stances— are peculiarly adapted to foster susceptibilities to nervous disease.
^ ^ ^ On the other hand, considerable exercise in the open air. with some
disregard of atmospherical conditions, serves to expend the surplus nervous
energies, and thus excite a healthier activity in the nervous system. Upon no
class of children does the hot-house management operate more unfavourably
than on that we are here considering. Upon no other class of children do
labour and exposure, properly regulated, prove more salutary; and parents
cannot make a greater nriistake than to lavish upon them the tenderest nursing.

" Of more importance, however, than all this, is the mental and moral training
— or. more strictly speaking, the education and exercise of the brain. This
must be managed with paramount reference to its health, to which every other
consideration should be subservient. This, of course, requires prudence and
discretion, a disregard of the more attractive objects of education, and a supe-
riority over the vulgar prejudices so prevalent on this subject. Whatever
habits or exercises are calculated to impair the mental health of any child must
necessarily favour the growth of morbid tendencies wherever they exist. Errors
which may be harmless to such as are happily organized, act with fearful effect
upon those who have inherited a proclivity to disease. The most pernicious,
and, at the same time, the most common of these errors in our present methods
of education, is to require an excessive amount of study. It is curious how few
have any other idea of the youthful brain, than that of a machine exempted
from the ordinary lot of wear and tear. * * *

" Children are made to study while yet too young. * * * But it is at a
later period, when the common repugnance to study is overcome by its glittering
rewards, that the danger begins. By one motive or another, the brain is stimu-
lated to an amount of application that would be excessive in adult age. The
requirements of teachers, the love of distinction, the thirst for knowledge, blunt
the sense of fatigue, and the usual ignorance or carelessness of nature's laws
utters no warning against the danger. Six. eight, ten hours a day, in school or
out, the mind is engaged in the most exhaustive exercise, and even the night is
not entirely given to rest. If anything is calculated to foster unhealthy tenden-
cies, it certainly is such management as this, because it vitiates and weakens
those energies on which we must chiefly rely in maintaining the health of the
brain against the influence of abnormal tendencies.

" Supposing the individual who has inherited tendencies to mental disease, to

have arrived at manhood and entered on the serious business of life, how shall

he prevent, if possible, the development of those tendencies into actual disease.
* *

" The necessity of ordering one's life with reference to this constitutional
defect being admitted, it must be premised that the same rules of living are not
equally 'applicable to all men. Difference of temperament, of education, of
taste, of pursuits, require diversity of management ; insomuch that a course of
living most salutary to one might be tilled with danger to another. * ^ *

1862.]

American Insane Hospital Eeports,

167

"Most persons have some weak point in their physical constitution, and this,
by a well-known law of the animal economy, is the first to suffer under any
general disturbance of the vital actions. AVhatever habit or indulgence, there-
fore, may be supposed, under the common rules of hygiene, to impair the vital
energies, should be carefully shunned. Good habits of living, abundant exercise
in the open air, unstinted sleep, plain, nutritious food, moderation and tempe-
rance in all things, beneficial as they are to all. are peculiarly important to those
whose hereditary tendencies expose them to mental disease. Especially are
stimulants, and whatever else is calculated to affect the nervous system, to be
used with extreme caution. I do not say that they are invariably and uncondi-
tionally injurious, but that they generally are when used to excess, and often
are, even when used with judicious moderation. Nobody, therefore, with the
morbid tendencies in question, and sincerely desirous of preventing their devel-
opment, will hesitate to deny himself all indulgence in tobacco and spirituous
liquors, not implicitly required by some other conditions. * * ^

" Excessive bodily exertion, by deranging some of the functions of organic
life, may thus indirectly occasion mental disease, and therefore should be cau-
tiously used by the class of persons in question. No small amount of insanity
in this country, especially among the young married American women of the
humbler classes, is produced by a dea-ree of daily toil greatly beyond their power
of endurance, and enlivened by insufficient recreation or amusement. ^ * *

" However important may be the physical regimen of persons predisposed to
mental disease, it is. unquestionably, upon their mental exercises that the fate
of the larger portion must chiefly depend. How these shall be ordered so as
to best secure the object in view — what kind and amount of mental application
shall be allowed — what moral and intellectual powers shall be cultivated or
neglected — these are Cjuestions to be carefully and intelligently considered. * *

•'By the class of persons whose case we are here considering, no more con-
servative agency can be had than that of suitable and steady employment. ^ *

'•It should require an amount of application much less than that deemed safe
and proper in more happily constituted minds. Here the brain is peculiarly
sensitive to any strain upon its energies, and being deprived of its proper elas-
ticity, it fails to recover itself completely when the tension is removed. A
degree of irritability, and perhaps of discomfort, is finally established, which
may be readily converted into disease. A full amount of mental labour, there-
fore, is out of the C|uestion. and it is the part of wisdom to recognize the fact
and conform to its requisitions.

The employment should be not merely an easy sort of drudgery or busy
idleness, bat one as interesting and useful as practicable, and adapted to the
person's taste and station. Simple occupation of the attention is better than
nothing, but it lacks those conservative influences which flow from the con-
sciousness of having accomplished something that needed to be done. It should
involve no great responsibility, nor subject one to unpleasant intercourse with
others. * * *

"From social pleasures of the simple, cpiiet kind, the happiest effect may be
expected; but absolute seclusion should not be more carefully avoided than
gatherings of people where the sound of passion is heard, and the heart and the
will are carried away captive by the irresistible power of sympathy. ^ *

Of any employment or recreation, it should be an indispensable condition
that it should not curtail the proper allowance of sleep, either by encroaching
on its regular hours, or by filling the mind with thoughts and images that refuse
to depart at bidding. Deficient sleep is a source of imminent peril, and when
it continues for several days, the appropriate remedies should be sought without
delay. * * ^

" When the morbid tendency begins to show itself, merely in unusual restless-
ness, there may be a craving for amusements and exciting scenes, which friends
are too ready to indulge, with no idea of the danger they incur. Nothing can
be more mischievous than such indulgence, calculated, as it is. to cherish the
kindling spark and fan it into an uncontrollable flame. ^ ^

" Persons predisposed to mental disease should carefully avoid a partial, one-
sided cultivation of their mental powers — a fault to which their mental const!-

168

Bibliographical Notices.

[July

tution renders them peculiarly liable. Let them bear in mind th-at every promi-
nent trait of character, intellectual or moral, every favourite form of mental
exercise is liable to be fostered at the expense of other exercises and attributes,
until it becomes an indication of actual disease. Here lies their peculiar danger,
that the very thing most agreeable to their taste and feelings, is that which they
have most to fear. Many of this class of persons possess a large endowment of
the ideal faculty. They delight to dwell in the regions of fancy, and the subjects
they habitually contemplate are such as the imagination only can supply. * * *
Such persons should beware how they yield to their favourite contemplations.
As a matter of safety, they should cultivate those faculties which are concerned
with objective or definite truths, such as those of mathematics, natural history,
and natural philosophy. These require a more equal and steady attention, and
are marked by more exact and tangible results, all well calculated to check that
roving movement of the mind, which, under whatever name it may pass, weakens
its powers of self-control, and thus invites the approach of disease. ^ ^

" There is another disposition of mind to be carefully shunned by the class of
persons in question — that of allowing the attention to be engrossed by some
particular interest to the neglect of every other, even of those most nearly con-
nected with the welfare of the individual. * ^ Where the mind of a person
revolves in a very narrow circle of thought, it lacks entirely that recuperative
and invigorating power which springs from a wider comprehension of things,
and more numerous objects of interest. The habit of brooding over a single
idea is calculated to dwarf the soundest mind ; but to those unfortunately con-
stituted, it is positively dangerous, because they are easily led to this kind of
partial mental activity, and are kept from running into fatal extremes by none
of those conservative agencies which a broader discipline and a more generous
culture naturally furnish. The result of this continual dwelling on a favourite
idea is, that it comes up unbidden, and cannot be dismissed at pleasure. Eeason,
fancy, passion, emotion — every power of the mind, in short — are pressed into its
service, until it is magnified into gigantic proportions, and endowed with won-
derful attributes. The conceptions become unnaturally vivid, the general views
narrow and distorted, the proprieties of time and place are disregarded, the
guiding, controlling power of the mind is disturbed, and, as the last stage of
this melancholy process, reason is completely dethroned. These persons should
be careful, therefore, how they suffer themselves to be led into the active support
of those prominent moral and social enterprises that abound in every community.
No matter what may be their convictions touching the necessity or justice of
these projects, or the claims they make on the sympathy of all good and true
men. They cannot join the ranks of those whose devotion to their favourite
cause knows no stint or measure, without serious peril to their mental integrity.
Let them, therefore, habitually feel that their mission in life lies in the quiet,
unobtrusive performance of those duties which are incumbent on all, rather than
in the promotion of enterprises which court the public gaze and stimulate their
energies to the highest possible pitch. Let them not be beguiled by any fanci-
ful obligations of duty, to quit the humbler sphere of effort most suitable to
their mental capacities. There will always be enough to take the prominent
places which they had better avoid, while no sphere of life is without its oppor-
tunities of useful and honourable effort." * *

Having thus written of the management of the intellect, the Doctor proceeds
to that of the moral or emotional faculties. He believes that, " to some extent
at least," persons "have the power of controlling their moral movements, and to
that extent of hastening or retarding an attack of disease." Every person having
a hereditary tendency to insanity should learn his own ruling sentiments, and, as
no one can see himself as others see him, he should have those sentiments pointed
out to him by his friends. These sentiments, making obliquities of character,
are various.

"In one, it is an inordinate love of money; in another, of fame and glory: in
another, of reforming social evils; in another, of projecting great benevolent
enterprises; in another, of intense religious excitement. The object pursued
may not be intrinsically bad ; on the contrary, it may be highly commendable
and worthy the attention of a rational being, and consequently the passion or

1862.]

American Insane Hospital Reports.

169

affection is indulged, until it shapes every movement and passes beyond the
control of the intellect. In fact, the more commendable the object, other things
being equal, the greater the danger, because entirely unsuspected. The daily
experience of life furnishes abundant illustrations of the subject, but my limits
forbid the notice of many.

" The sentiment of benevolence, allying us, as it does, to the great Giver of all
good, would seem, at first thought, less likely than any other to be the source
of an unhealthy activity, and yet -when so strong as to be the predominant trait
in the moral constitution, it is liable, in the class of persons under consideration,
if not carefully watched, to lead to the most painful results. When thus in-
dulged, life, duty, right and wrong, God and man. are often viewed solely by the
light of this sentiment, with none of those softening shadows which the rest,
under a more equal cultivation, would impart. Justice, discretion, expediency,
even right, must all yield to the mere impulses of benevolence, which recognizes
no degrees or shades in moral obligation. Oppression under any and every
form must be immediately abated by an appeal to force; reforms are to be thrust
upon the world, regardless of time and season ; abuses are to be torn up by the
roots, careless of the healthy growth around that may be injured by the pro-
cess ; and individuals are held to be responsible for any wrong with which they
may be ever so remotely connected. Whatever is, is absolutely right or abso-
lutely wrong, to be fondly cherished or summarily destroyed. Xo palliation of
the evil is to be found in the attending circumstances; no remedy is to be tole-
rated that implies any prospective change in the delinquent. Thus, it becomes,
at last, to be regarded as a sacred duty to vindicate the claims of abstract bene-
volence at whatever hazard, even though it lead through seas of blood and fire.
Instances of this moral obliquity are not rare in the world, and so imperfectly
is their character understood, that it is an equal chance whether they pass for
fanatics, madmen, or hardened criminals. Looking at them in their true psycho-
logical relations, we need to have no doubt on this point. Let those, therefore,
to whom the warning is peculiarly necessary, who find themselves deeply inte-
rested and engaged in promoting benevolent enterprises, reflect that, little as
they may suspect it, every day is bearing them beyond the reach of those health-
ful activities which prevent eccentric movements of the mind from passing over
the limits of safety.

"Again, no sentiment of our nature is more generally cultivated, in all Chris-
tion communities, than the religious ; and, connected as it is with the highest
interests of the individual, it is not strange that it should often be excessively
exercised, and strained beyond the point of healthy endurance. In persons of
ill-balanced minds, this result is almost inevitable, unless prevented by timely
precaution and management. The elevated themes which engage their atten-
tion are allowed to withdraw the mind from every other, apparently inferior
object, with the usual result of narrowing the intellectual range, and disturbing
that rightful balance of the faculties which always characterizes the most effi-
cient order of minds. Gradually and unconsciously they reach a point where
they have no thought for any thing else but their favourite themes. Intense and
constant meditation upon them is followed, sooner or later, by its legitimate
results — excessive extravagance of thought, unnatural rapidity of the mental
movements, startling imagery, irrational combinations of ideas, and downright
delusion."

" The danger in this class of cases is all the greater, because the sentiment is
pre-eminently social in its character, and its indulgence is greatly affected by the
power of sympathy. The example of multitudes engaged in similar exercises,
encouraging and emulating one lan other in the intensity of their feelings, has a
mighty influence, even upon the most sluggish spirits, while upon those of mor-
bid proclivities, it often operates with irresistible force, sometimes when least
expected, and breaks down every barrier that reason can place in its way. This
is not a rare and exceptional phenomenon. In the tables of causes contained
in the reports of many of our hospitals for the insane, many cases are always
attributed to ' religious excitement.' "

(Two or three cases, from the thousands upon record, are here given.)
The voice of admonition too often falls on unwilling ears, for people are

ito

Bibliographical Notices.

[July

slow to believe that exercises which are hip^hly meritorious, because leading to
a good result, and prompted, perhaps, by divine influence, can, by any possi-
bility, be dangerous to the mental health. Indeed, it seems to them little short
of impiety to suppose it. Let them remember that they are yet in the flesh, and
that no pursuit or exercise, however commendable, can be successfully followed
by a system of means not in accordance with the laws of the animal economy.
They may be sure that these will not be suspended to enable them to accomplish
a desirable end ; and they may be also sure, that divine influences are always in
harmony with those natural laws which have proceeded from the same beneficent
source. Those who are sincerely desirous of guarding against the development
of morbid tendencies, should carefully avoid all scenes of religious excitement,
indulge their religious emotions in quiet and by ordinary methods, always allow-
ing other emotions and other duties their rightful share of attention. Kegulated
in this manner, the religious sentiment will be to them, not only a source of
spiritual comfort, but a power more efficient, it may be than any other, for
maintaining the healthy balance of the faculties, and keeping in abeyance the
hereditary proclivities to disease."

" If I have said nothing of the danger to be apprehended from the indulgence
of other passions — envy, anger, jealousy, pride, fear or grief — it certainly is not
because such indulgence is harmless to the health of the mind, even in those
most fortunately constituted. In the ordinary intercourse of life, we not unfre-
quently meet with persons who, with all the force of an instinct, view whatever
passes around them with a jealous eye — ever ready to find, in the sayings and
doings of others, evidence of hostility or unfriendliness to them, and to see, in
the most trivial occurrences, matured designs of annoyance. They are con-
stantly breaking with their best friends, and spend their whole life in converting
the innocent occasions of private and public intercourse into pretexts for cold-
ness and disafiection. In others, again, the ruling passion is envy. Their bless-
ings, whether small or great, are of little satisfaction, because others are enjoying
w^hat seem to them greater. Favors bestowed on others are regarded as proofs
of the most culpable neglect of their superior deserts. They feel as if every
one who has any reason to rejoice in the good things of life, is guilty of a positive
wrong towards them, and bound to make restitution and recompense. Persons
of this description — inheriting tendencies to disease and ruled by some pre-
dominant passion — are never far removed from the brink of insanity, over which
they are liable to be precipitated by the first adverse incident that severely tries
their power of endurance. Early judicious discipline might have repressed the
growth of the passion, and, to that extent, have secured the future integrity of
the mind."

2. Although the New Jersey State Lunatic Asylum is among a people who
were somewhat cautious and tardy in the recognition of its excellence, its officers
may now be well satisfied with the appreciation of its merits. In the language
of the report — " the house has been much crowded through the entire year,
notwithstanding the removal of a pretty large number — seventy-four — of chronic
cases.

" Many of these, though regarded as incurable, were still proper subjects for
care and treatment in the asylum, and were only removed by the public authori-
ties, or by friends, upon the urgent request of the officers of the institution, to
make room for other and more necessitous cases."

Patients in the asylum, December 31, 1859 .
Admitted in the course of the year .

Whole number

Discharged, including deaths
Remaining, December 31, 1860 .
Of those discharged, there were cured

Whole number of cases from May 15, 1848

Pecovered

Died

Died .

Men. Women. Total,

141 165 306

85 89 174

226 254 480

72 98 170

154 156 310

28 45 73.

15 8 23

830 907 1737

320 358 678

123 106 229

1862.]

American Insane Hospital Reports.

171

Deaths in 1860. — From consumption, 2; epilepsy, 3; exhaustion of acute
mania, 9 ; apoplexy, 1 ; softening of brain, 1 ; exhaustion of chronic mania, 4 ;
dropsy, 2 ; uncertain," 1.

In two cases of fatality from the exhaustion of acute mania death occurred
within a few hours after the patients arrived at the hospital. Dr. Buttolph very
properly remarks, that "it is often an important question to decide whether a
patient in an acute attack, who has been several days and nights without regular
food and rest, and who has made much exhausting effort, may not be too much
prostrated in strength to bear a fatiguing journey from home to the asylum.
The removal should at least be advised by the medical attendant in charge, who
should point out such precautionary measures in accomplishing it as will tend
to relieve the patient, as far as possible, of exhausting effects."

In view of the crowded state of the hospital, and the numerous applicants for
its benefits, Dr. Buttolph, after asserting that additional accommodations for
the insane of the State are urgently demanded, discusses the question whether
those accommodations shall be obtained by the enlargement of the present hos-
pital, or by the erection of another. He concludes that, notwithstanding the
present number of patients in his establishment is upwards of 300, " the number
may be somewhat increased without materially increasing the difficulty of its
oversight." He mentions the numerous advantages of the location, and pro-
poses, "if the policy of enlarging the present structure be adopted, to provide
rooms for one hundred more patients."

Three hundred and ten (the present number), plus one hundred, equals /oitr
hundred and ten. How happens it that "in the abstract," "theoretically," "as
a general rule," the members of the Association of Medical Superintendents
assert that tiuo hundred and fifty is the utmost proper limit to the number of
patients in a hospital, and yet, whenever the principle is to be adopted or
rejected in any one of their individual cases, they " go in" for the enlargement
ad libitum of their already overgrown establishments. " Logic is logic," but
theory is not always practice.

219

153

372

250

177

427

222

157

379

3. The report before us of the Western Lunatic Asylum of Virginia embraces
a period of fourteen months, ending with the 30th of November, 1860 ; and,
although Dr. Stribling is not remarkable for prolixity, he has, in this instance,
been unwontedly brief.

Men. Women. Total.

Patients, October 1, 1859 ....
Admitted in course of fourteen months

Whole number

Discharged, including deaths
Eemaining, November 30, 1860 .
. Of those discharged, there were cured
Died

It appears that a very large proportion of the patients in this hospital are
incurable, and as no provision has here been made for the removal of harmless
cases of this class, either to their homes or to other receptacles, the number of
admissions is small for so large an insti1?ution. Of 250 applicants in the course
of fourteen months, only 53 were received. These, as was supposed, were such
as were the most curable, and were selected, in the exercise of a discriminative
power, by the Superintendent. The exercise of the power mentioned often, as
may readily be conceived, gives offence, and Dr. Stribling suggests that a law
be enacted for the removal of old demented cases to the county almshouses, thus
opening the way to a more general admission of new applicants.

A third hospital for the insane within the State is thus mentioned in the
report : " I am not apprised as to when it is expected, by those in charge, to
have accommodations for the insane at Western Virginia. If the entire build-
ing being erected must be completed before patients are admitted we can but
fear the day is somewhat remote when these sufferers will find an asvlum there."

172

Bibliographical Xotices.

[July

4. The report for 1860, of Dr. Parker, of the State Lunatic Asylum of South
Carolina, is brief, and presents but few points of other than local interest.

Patients at the beginning of the year 194

Admitted in course of the year 69

Whole number 263

Discharged, including deaths 71

Remaining at the end of the year 192

Of those discharged, there were cured 37

Died 26

Of the 192 remaining at the end of the year, 86 were males and 106 females.
The predominance of females is attributed to the rejection of many male appli-
cants, for the want of proper accommodations. An additional section to the
new building is in progress.

" There has been an unusual number of applications for the admission of male
slaves. The removal of all males from the old buildings and grounds made it
necessary to remove the coloured patients of that sex, since which time we have
had no place for that class. In consequence, many persons in the country are
embarrassed with insane servants, and earnestly beg that influence be exerted
with the legislature for some provision to be made which will relieve them from
the responsibility and danger of keeping such patients at home, without the
proper means of their comfort and cure. Insane coloured women we continue
to receive, and have been fortunate in sending several to their homes, ready and
competent to discharge their usual duties.

" Since the occupancy of the old building exclusively by females, it has under-
gone repairs and is improved in many respects, especially in the general arrange-
ment and classification of the patients, all of which is very perceptible, and has
been productive of uniform contentment among them.

" To Miss D. L. Dix we are largely indebted for her prompt response to an
invitation extended by the Regents. At their call she visited our Asylum, with
peculiar interest in behalf of its inmates, though herself in feeble health, spent
her time at the capital, and with indomitable zeal and perseverance, discreetly
and modestly exercised, successfully brought to the notice of every member of
our Legislature the claims of our insane."

5, The subjoined statistics are taken from the report of the Northern Ohio
Lunatic Asylum, for the fiscal year ending October 31, 1860 : —

Men. Women. Total.

Patients at the beginning of the year . .66 72 138

Admitted in the course of the year . . . .o2 63 II.t

Whole number 118 13.5 253

Discharged, including deaths . . . . 54 64 118

Remaining at the end of the year ... 64 71 135

Of the discharged, there were cured ... 23 31 54

Died 2 2

Died from "exhaustion," 1 ; congestion of the brain, 1.

"The health of the inmates," says iTr. Kendrick, " has been uniformly good
during the year. The physical disorders incident to hospital life have been mild
in form and readily controlled by ordinary hygienic precautions and simple
remedies. A procrusteau plan of treatment is as little applicable to the insane
as to the sane. We do not think of adapting the patient to the remedy in phy-
sical disease ; so in mental disorder, which is but a manifestation of a diseased
brain, we must modify our treatment to suit the varying wants of each case.

" The nearer the approach to individualized treatment in our hospitals —
other things being equal — the greater the success. The percentage of recoveries
will be increased in direct ratio with the increase of resources ; proper classifica-
tion, appropriate labour, constant mental employment, so diversified as not to
weary, are indispensable to a successful treatment of the insane. They may as
well be confined in the infirmaries and jails of their counties as in our public

1862.]

American Insane Hospital Reports.

IIS

hospitals, if debarred, by narrow rainded views of economy, from that extensive
range of employment and amusement now so universally furnished the insane in
curative institutions. I am sorry to say that our institution is behind the age
in these respects. Great changes must take place to bring it up to that high
standard of excellence, to which a worthy ambition prompts us to aspire."

6. The general results of treatmenl at the Hamilton County [Ohio) Lunatic
Asylum, for the year ending June 5, 1859, were as follows : —

Patients at the beginning of the year
Admitted in the course of the year
Whole number ....
Discharged, including deaths
Remaining at the end of the year
Of the discharged, there were cured
Died

Men. Women.
112- 118

105
217

74
143

43
5

59
177

47
130

Total.

230

164

394

121

273

Died from maniacal exhaustion, 3 ; nephritis, 2 ; epilepsy, 2 ; marasmus, 2 ;
chronic dysentery, 2 ; purpura, 1 ; paralysis, 1 ; gastritis, 1 ; phthisis, 1 ; delirium
tremens, 1 ; suicide, 1.

"As heretofore, and as must always necessarily be the case under conditions
similar to those affecting us, the diseases attacking our inmates, no matter what
may have been their type primarily, speedily assume an asthenic character,
requiring the most prompt, efficient and persistent stimulating plan of treatment
to successfully combat them."

Of the 394 patients, 289 were foreigners and 105 natives of the United States.

" From changes of scene, of climate, and mode of life, separation from friends,
regrets and yearnings for home, annoyances and misfortunes suffered and diseases
contracted on ship passage, disappointed prospects, blighted hopes, poverty, ill
health, and the too general prevalence of intemperance — that fruitful source of
insanity among them — many a poor emigrant is driven to madness who would
never have been bereft of reason had he lived and died in his native land."

It will perhaps be remembered, that the buildings of the Hamilton County
Asylum were intended only for temporary use. At the time of the publication
of the report before us, the new buildings specially erected for the institutioQ
were far advanced toward completion.

7. The report for 1858 of the Insane Asylum of California, extends over a
period of but eleven months, the official year being made to close with the close
of the month of November.

Patients in asylum Jan. 1st

Admitted

Whole number ....
Discharged, including deaths
Remaining Nov. 30th .
Of the discharged, there were cured
Died

Men. Women. Total,

156

188

201

244

357

432

133

159

224

273

112

The diseases terminating fatally are not reported.

" In California," says Dr. Aylett, " the sick have few friends, and are therefore
quickly dispatched to the hospital. In this way the heartless stranger proves,
really, the best friend of the poor lunatic." The very large proportion of cures
at this hospital, as shown by the foregoing statistics, is undoubtedly, as inti-
mated in the report, to be attributed to the fact that the patients are placed
under hospital treatment at a very early period of the disease. "We here have
a practical argument in favour of early treatment which should be neither over-
looked nor forgotten.

Dr. Aylett's report is brief, and mostly confined to the financial department
of the hospital. We infer from it that an economy so rigid is required that there

174

Bibliographical Notices. * [July

i?s an impossibility of furnishing those abundant facilities for moral treatment
which are found at some other institutions. "For a few months," says he, "we
had the use of a billiard-table, for which we were indebted to the kindness of
Mr. Butler, the architect of the late improvements. I was surprised to find
how much interest was taken in the game by some of the patients, who were
thus beguiled of many a tedious and melancholy hour."

But the following extracts have a pleasant look : "I do not hesitate to say
that the improvements effected by the labours of the patients in the last twelve
months would have cost, at the usual rate of labour, at least fifteen thousand
dollars. * * * After the month of May, I hope and expect to dispense with a
vegetable bill altogether. We have one thousand thrifty trees, of all varieties
of fruit, from which we may expect a most abundant crop in a couple of years.
We ought to set out about three thousand grape-vines this winter, and for this
. purpose, and for the purchase of tools, seeds, etc., we need an appropriation of
five thousand dollars."

8. The Wisconsin State Hospital for the Insane was begun several years ago,
but its progress toward completion was checked by many obstacles, both finan-
cial and political. The officers first elected having been removed, others were
appointed to their places, and, after many vicissitudes, the central building and
one wing of the hospital were prepared for the reception of patients. The es-
tablishment was opened on the 14th of July, 1860, under the care of Dr. John
P. Clement, who had previously been connected, as Assistant Physician, with
the Hospital at Brattleboro', Vermont. The Trustees, in their report, present
to the Governor, and through him to the people of the State, the following con-
solatory and congratulatory words : —

"As some relief to the disappointment and vexation which this institution
has hitherto created upon the public mind, we are now able to present the con-
soling intelligence that when the balance of indebtedness above set forth
($50,000) shall have been paid, the committee believe that no remaining debt
will exist against the institution from any source whatever. It argues much, in
behalf of the generosity of the people of Wisconsin that in the midst of unpa-
ralleled pecuniary embarrassments, they have contributed directly and so largely,
from their scanty means, to procure the erection of this much needed institution,
for the relief of that unfortunate class of their fellow-citizens who have been
deprived of their reasoning faculties. But they have at length the cheering
consolation, that through much struggling and adversity, they have patiently
persevered in behalf of such as are deprived of those noble attributes which
constitute the manhood of man, till they have succeeded in establishing a proud
and enduring monument to their humane instincts, and sympathizing benevolence.
And, though the struggle has been long and arduous, we are happy to believe,
that with a little more skirmishing, the victory will be completely and nobly
won,"

The report is dated December 16th, a little more than five months after the

hospital was opened.

Men. Women. TotaL

Patients received to that time .... 43 46 89

Discharged, including deaths .... 3 8 11

Kemaiuing^ 40 38 78

Of the discharged, there were cured ... 3

Died 3

Died from exhaustion in puerperal mania, 1 ; phthisis, 1 ; softening of the
brain, 1,

" Of those remaining, four at least have recovered and will soon be discharged,
making the recoveries seven in all. There are, perhaps, ten others whose reco-
very may be reasonably expected. A few others will probably be sufficiently
improved to render their return home advisable.

" The large number of remaining cases are incurable, and incapable of any
material improvement. Still, their condition is ameliorated by care and treat-
ment in an institution specially designed for them. The violent are managed

1862.] Brown-Sequard, Paralysis of the Lower Extremities. 175

with much less restraint and coercion than would be necessary at their homes,
or in jails and poor-houses. The filthy are often rendered more cleanly, and the
noisy more quiet and orderly. The homicidal often become harmless. Two
patients are now quietly walking our wards, whom it was thought necessary to
chain, for a long time, at their homes."

Dr. Clement alludes to the evils arising from the attempt to treat both sexes
in one wing of the building, as well as from the gathering of nearly a hundred
patients into apartments designed for but about thirty, and appears anxious to
have another section of the edifice erected. P. E.

A RT. XYIT. — Lectures on the Diagnosis and Treatment of the Principal Forms
of Paralysis of the Loiver Extremities. By E. Brown-Sequard, M. D., F. R. S.,
Fellow of the Royal College of Physicians of London, Hon. Fellow of the
Faculty of Physicians and Surgeons of Glasgow, Laureate of the Institute of
France (Academy of Sciences), etc. etc. 8vo. pp. 118. J. B. Lippincott &
Co. : Philadelphia, 1861.

The substance of this excellent work originally formed part of a course of
lectures on various subjects delivered by Dr. Sequard, in April and May, 1859,
to classes of physicians and students in the Universities of Edinburgh and Glas-
gow, and in DulDlin. Its leading object is to point out the extreme importance
of a clear diagnosis of the various forms of paralysis of the lower limbs, and
especially of the two most frequent and distinct varieties, viz. : reflex paraplegia
and paralysis due to myelitis.

In the treatment of paraplegia it is well known that strychnia, brucia, phos-
phorus, sulphur, mercury, ergot, belladonna, and cantharides, have been em-
ployed, sometimes with marked benefit and sometimes with injury to the patient.
These drugs differ very considerably in their action upon the spinal cord. Some
of them, as strychnia and brucia, increase the quantity of blood in the vessels
of the medulla, while others, as mercury, ergot, and belladonna, diminish it. It
is very evident, therefore, that if we do not carefully discriminate between the
different kinds of paraplegia we must often commit serious errors in the treatment
of this disease. For all the cases of paraplegia are divisible into two general
groups : one in which there is an excessive quantity of blood circulating in the
spinal cord ; the other, in which the amount of this fluid is too small. Now the
whole history of reflex paraplegia shows that it is accompanied, and most likely
produced, by an insufficiency of blood in the cord. Remedies tending to dimi-
nish the quantity of this fluid still more should, therefore, be avoided. Never-
theless, mercury is often and very unwisely employed in the treatment of just
such cases. On the other hand, cases of myelitis, in which the opposite condi-
tion exists, are often treated with strychnia, the very remedy which so decidedly
increases the amount of blood in the cord.

In his second lecture our author places the practical physician under great
obligation by carefully detailing the striking differences which exist between the
symptoms of reflex paraplegia and those of the various forms of paraplegia of
centric origin. In the following table which we borrow from his pages, and
which is based upon numerous cases observed by Stanley, Rayer, Leroy d'Etiol-
les, Jr., Landry, Macario, Spencer Wells, Sequard himself, and others, are con-
densed the principal features of two of the most characteristic varieties of reflex
and centric paralysis of the lower extremities — -the paraplegia due to a reflex
influence originating in the urinary organs and the paraplegia produced by
myelitis : —

URINAEY PARAPLEGIA. PARAPLEGIA FROM MYELITIS.

1. Preceded by an affection of the blad- 1. Usually no disease of the urinary or-
der, the kidneys, or the. prostate. gans except as a consequence of the para-
lysis.

2. Usually lower limbs alone paralyzed. 2. Usually other parts paralyzed besides

the lower limbs.

176

Bibliographical Notices.

[July

TJKINARY PARAPLEGIA.

3. No gradual extension of the paralysis
upwards.

4. Usually paralysis incomplete.

5. Some muscles more paralyzed than
others.

6. Reflex power neither much increased
nor completely lost.

7. Bladder and rectum rarely paralyzed,
or, at least, only slightly paralyzed.

8. Spasms in paralyzed muscles extremely
rare.

9. Very rarely pains in the spine, either
spontaneously or caused by pressure, per-
cussion, warm water, ice, &c.

10. No feeling of pain or constriction round
the abdomen or the chest.

11. No formication, no pricking, no dis-
agreeable sensation of cold or heat.

12. Anaesthesia rare.

13. Usually obstinate gastric derange-
ment.

14. Great changes in the degree of the
paralysis corresponding to changes in the
disease of the urinary organs.

15. Cure frequently and rapidly obtained,
or taking place spontaneously after a nota-
ble amelioration or the cure of the urinary
affection.

In cases of myelitis the urine is almost always alkaline: while in cases of
reflex paraplegia, not depending upon a disease of the urinary organs, it is
usually acid, as in health. Paraplegia depending upon spinal meningitis may
be distinguished from reflex paraplegia by a rigid spasm of the muscles of the
back by the intense pain caused by motion of the lower limbs or of the spine,
or by the spontaneous acute pains that radiate from the spine to the lower
extremities, and the frequency of cramps. AYhen paraplegia is produced by
the pressure of a tumour, a diseased bone, or fibro-cartilage upon the spinal cord,
there is usually a feeling of tightness, or pseudo-neuralgic pain, or a degree of
formication, only in the parts of the body receiving their nerves from that part
of the cord which is pressed upon, unless there is a myelitis or a meningitis, in
which case these symptoms may exist in all parts of the body below the seat of
pressure. At this point there is also pain or tenderness. In cases of paralysis
of the lower limbs produced by a tumour in the gray matter of the spinal cord
anaesthesia appears at the onset of the affection, and may be more marked than
the loss of motor power. Keflex power in the parts of the cord below the tumour
becomes extremely exalted, so that very slight excitations will produce the most
violent reflex movements. The only great differential characteristic of hysterical
paraplegia is, that the paraplegia has followed hysteria. Our author thinks it
probable that in most cases, if not in all, hysterical paralysis is but a reflex para-
lysis. Paraplegia caused by hemorrhage in the spinal canal is characterized by
the existence of a vague pain along the spine some time before the paralysis
appears by the suddenness of its appearance, and by the very frequent occur-
rence of violent convulsions, or, at least, of spasmodic twitchings. When blood
is efi'used into the gray matter of the spinal cord the resulting paraplegia appears
suddenly and is always accompanied by a notable diminution of sensibility. In
paraplegia produced by congestion of the spinal cord and its membranes, the
patient, on rising after a night's rest, is much more paralyzed than when he has
been moving about, or has remained in a sitting posture for some time. • The
reverse of this is usually observed in reflex paralysis. Paraplegia is sometimes
caused by non-inflammatory softening of the cord, and may be distinguished
from reflex paralysis by the absence of any external cause of spinal irritation,

PARAPLEGIA FROM MYELITIS.

3. Most frequently a gradual extension of
the paralysis upwards.

4. Very frequently paralysis complete.

5. The degree of paralysis is the same in
the various muscles of the lower limbs.

6. Reflex power often lost, or sometimes
much increased.

7. Bladder and rectum usually paralyzed,
completely or nearly so.

8. Always spasms, or, at least, twitchings.

9. Always some degree of pain existing
spontaneously, or caused by external exci-
tations.

10. Usually a feeling as if a cord were tied
tightly round the boundary at the upper
limit of the paralysis.

11. Always formications, or pricking, or
both, and very often sensations of heat or
cold.

12. Angesthesia very frequent, and always,
at least, numbness.

13. Gastric digestion good, unless the
myelitis has extended high up in the cord.

14. Ameliorations very rare, and not fol-
lowing changes in the condition of the uri-
nary organs.

15. Frequently a slow and gradual pro-
gress towards a fatal issue ; very rarely a
complete cure.

1862 ] Beown-Seqtjard, Paralysis of the Lower Extremities, 111

by the very slow development of the paralysis, and sometimes by the arcus
senilis, and the presence of a calcareous deposit in superficial bloodvessels of
the head or limbs, &c. Paraplegia due to an obstacle in the circulation of blood
in the aorta, or in its principal ramifications in the pelvis, may be recognized by
the alternations of nutrition and pains in the paralyzed limbs, and especially by
the rapid increase of the paralysis after every notable exertion of the lower limbs,
and the return of some power after rest. Paraplegia resulting from pressure
on the pelvic nerves is accompanied by violent pains in the pelvis and in many
parts of the lower limbs by the production of cramps, &c.

Our author denies the existence of cases of the so-called essential or idiopathic
paraplegia, and maintains that other forms of this disease, such as those which
are connected with gout, rheumatism, or those which follow grave fevers, cholera,
&c., either depend upon venous congestion of the cord, and serous effusion into
the spinal canal, or belong to the group of reflex paralyses. Paraplegia is
sometimes a result of poisoning by carbonic acid, lead, arsenic, mercury, opium,
belladonna, tobacco, camphor, mushrooms, fish, &c. Great loss of blood, con-
cussion, fracture, or luxation of the spine, also produce this disease. In all such
cases the diagnosis is rendered easy by a knowledge of the cause.

In treating a case of reflex paraplegia our remedies must first be directed
against the external cause of the affection, and, secondly, against the paralysis
itself. The nephritis, cystitis, pneumonia, enteritis, or other morbid condition
which may be the cause of the paralysis, must be carefully treated. In the next
place we should endeavour to prevent or to diminish the transmission of any
nervous influence from the diseased nerve or organ to the spinal cord. For this
purpose we must try, by the use of narcotics and anodynes, to paralyze for a
time the sensitive nerves engaged in conveying the morbid influence. To di-
minish pain or to prevent reflex action, no narcotic is more powerful than bella-
donna locally employed.

" In cases of disease of the urethra or the prostate, an injection of a solution
of one grain of the extract of belladonna, in twenty drops of laudanum, is to be
made into the urethra, and the injection should be retained half an hour, or even
an hour, after which some emollient decoction should be employed to wash away
the rest of the narcotics. Every two or three days the same operation should
be repeated. In the intervening days, I advise the use of an injection of thirty
drops of laudanum without belladonna. In cases of a disease of the bladder, I
recommend the use of an injection into the bladder of a solution of one grain of
the extract of belladonna, in twenty drops of laudanum, just after a complete
emission of urine. One day this injection is employed, and the next day twenty-
five or thirty drops of laudanum alone are injected. When the prostate is very
much enlarged, a suppository, covered with a belladonna-and-opium ointment,
ought to be put at times in the rectum.

" When the irritation that causes a reflex paraplegia starts from the vagina
or the uterus, a pill of half a grain, of extract of belladonna with one grain of
extract of opium, surrounded by a piece of cotton wool, is introduced far into
the vagina, and even up to the neck of the uterus. By means of a thread at-
tached to the cotton, it is withdrawn as soon as the pain has ceased or much
diminished. This simple means I have seen often employed with benefit by my
learned teacher, Professor Trousseau, in painful- affections of the womb, and I
have myself made use of it with great advantage in two cases of reflex para-
plegia, and in several cases of hysterical paralysis.

" In cases of a reflex paraplegia due to dysentery, colitis, or other morbid
irritations of the large intestine, accompanied by diarrhoea, opium alone — z, e.,
without belladonna — should be employed in enemata. In cases of paraplegia
due to teething, if it coexists with enteritis, as it often does, opium is the nar-
cotic to be employed, and it should then be taken by the mouth in very small
but repeated doses. In cases of neuralgia producing a paraplegia, the narcotic
that should be chiefly employed to relieve pain is opium, and so also in cases of
paraplegia due to a disease of the stomach, the liver, the kidneys, the pleura? ;
but even in all these cases, belladonna may be used with profit if united with
opium, if it is not often employed, and especially if strychnine is also used at the
same time. I could not insist enough upon the importance of the necessity of
No. LXXXYII.—JuLY 1862. 12

178

Bibliographical Notices.

[July

never using belladonna -without employing-, at the same time, strychnine and
opium, or, at least, strychnine, in cases of reflex paraplegia. I must repeat, also,
that in this affection, when belladonna is employed, its use ought not to be a
constant one ; and, if the patients are not very costive, opium ought always to
be the principal narcotic used to alleviate the external irritation that causes the
paralysis."

The great object of this narcotic treatment is to bring about dilatation of the
bloodvessels of the spinal cord, and a consequent increase in the amount of blood
circulating in these vessels.

Excitants or revulsives applied to the skin of the legs, as recommended and
successfully practised by Graves, the application of cold to the spine, and the
employment of galvanism are all very useful in the treatment of many cases of
reflex paraplegia. Their mode of action probably consists, according to our
author, in producing for a short time the same effect as the irritation, which is
the cause of the paralysis — i. e., a contraction of the bloodvessels of the spinal
cord ; but. according to a well-established law, if such a contraction becomes
considerable, the muscular fibres are soon exhausted, and a relaxation of the
contracted fibres takes place, and, as a consequence of this relaxation, a dilata-
tion of the bloodvessels occurs.

" To those patients who can bear the application of very cold water to the
spine," says Dr. Brown-Sequard, "I prescribe the use of a douche thrown with
great force all along the dorsal and lumbar regions of the spine. The douche
should be applied for one minute or a minute and a half ; it ought to be supplied
with a small jet, and the temperature of the water should be between 40^ and
50^ Fahr. I need hardly say that the spine must be rubbed hard with a warm
flannel immediately after the application of the douche. In patients who can-
not bear the cold douche, a very warm douche should be made use of. I some-
times make use of alternate applications of cold and heat, either with sponges
— one soaked with ice-water, and another with water at 100^ Fahr. — or a towel
folded somewhat like a cravat, the two ends of which are wet, one with ice-water,
the other with warm water, the spine being struck with either end of this towel
alternately."

In order to increase still further the quantity of blood in the spinal cord. Dr.
Brown-Sequard gives the following directions concerning the position of the
patient in bed.

" Every night, and often in the course of the day, the patient should lie down
on his back, placing his head, his arms, and his legs, on high pillows, so as to
produce by gravitation a congestion in the spinal cord. This simple means,
which is also applicable in cases of hysterical paraplegia, and in almost all the
cases in which there is an insuflBcient amount of blood in the spinal cord, is just
the reverse of what should be done in cases of inflammation or congestion of
the spinal cord or its membranes, or of disease of the spine, <fcc., in which cases
the patient ought to lie flat on the abdomen, or on one side of the body, and
have his feet and hands on a much lower level than that of the spine."

The remedies most useful in cases of reflex paraplegia are essentially those
which increase the amount of blood in the spinal cord, and augment the vital
properties of this nervous centre. Remedies which render the blood richer in
nutritive principles are also requisite. Of all known agents strychnia most
powerfully increases the vascularity, and, consequently, the nutrition of the
cord. The researches of Bonnefin have shown that morphia, nicotine, picro-
toxine, cyanuret of mercury, sulphuret of carbon, chloride of barium, oxalic
acid, &c., seem to act like strychnia upon the medulla spinalis. Compared with
the latter remedy, however, they are deserving of but little confidence in the
treatment of reflex paraplegia. In this disease, as we have already seen, the
amount of blood in the cord, and the reflex faculty of this organ, are both di-
minished. As strychnia counteracts both these conditions — or, in other words,
increases most decidedly the quantity of blood, and the reflex power of the, cord
— it becomes, in the hands of the discriminating physician, a powerfully curative
agent. "When used alone, one-twentieth of a graiu should be given in the course
of a day. When employed in conjunction with opium, the dose should be re-
duced to from one-fortieth to one-thirtieth of a grain per day. When given in

1862.]

Sims, Tedder, Gay, Surgical Tracts.

combination with belladonna, the dose must be larger, on account of the anta-
gonistic action of belladonna on the spinal cord. Dr. Brown-Sequard also re-
commends sulphuret of potash baths, made in the proportion of four or five
ounces of the salt to sufficient water for a bath.

In his third lecture, our author dwells at length upon the diagnosis and treat-
ment of paraplegia due to myelitis, meningitis, and simple congestion of the cord.
The fourth and last lecture is devoted to a consideration of the symptoms and
treatment of the various forms of paraplegia produced by white, or non-inflam-
matory softening of the cord, by hemorrhage into the substance of the medulla
or into the vertebral canal, and by tumours pressing upon the cord. Both these
lectures abound in such valuable information and suggestions relative to the
nature and treatment of paralysis of the lower extremities, that we cannot too
strongly urge a careful perusal of them upon those of our readers who may be
called upon to treat cases of this troublesome and distressing affection. The
work, as a whole, is free from mere theoretical discussion, and is remarkable for
the clear and concise manner in which the facts of physiological and clinical
observation are combined in the attempt to establish a scientific and successful
method of treating the important disease under consideration. J. A. M.

Art. XYIII. — Surgical Tracts.

1. Amputation oftlie Cervix Uteri. By J. Marion Sims, M. D. Extracted
from the Transactions of the State of New York, 1861. New York, 1861.
8vo. pp. 16.

2. Extension and Counter-extension in the Treatment of Fractures of the
Long Bones ; with a Description of an Apparatus especially designed for
Compound Fractures. By Joseph H. Yedder, A. M., M. D. New York,
1862. 8vo. pp. 23.

3. A Description of the newly -invented Elastic Tourniquet, for the Use of
Armies and Employment in Civil Life, its Uses and Applications, ivith
Remarks on the Different Methods of Arresting Hemorrhage from Gun-
shut and other Wounds. New York, 1862. 8vo. pp. 31.

4. On Intestinal Obstruction hy the Solitary Band. Being a paper read at
a meeting of the Medical Society of London, March 25th, 1861, and re-
printed from their Transactions. By John Gay, F. R. C. S., &c. London,
1861. Printed for private circulation. 8vo. pp. 16.

1. Dr. Sims records in this paper nine cases in which amputation of the
cervix- uteri was performed by a method more simple and safer than the one
usually adopted. The cervix is split laterally, and the anterior and posterior
halves are removed by means of scissors. After the hemorrhage has ceased,
the vaginal mucous membrane is drawn over the stump and secured by four
sutures, two on each side of the cervical opening. According to this plan there
is no suppuration, the parts healing by the first intention, and the parts becoming
well in a week. In the old method of amputation, the suppuration continued
five or six weeks, sometimes longer, before the parts entirely cicatrized.

This paper is illustrated by four wood-cuts.

2. The pamphlet of Dr. Yedder, though the title would lead one to look
for something more, contains simply the description of some mechanical con-
trivances for making extension and counter-extension in the treatment of
fractures.

The mode of making extension contrived by Dr. Yedder is that of having on
the outside of the splint a ratchet pulley, into which is fastened a strong cat-
gut cord or linen twine that runs over the extremity of the splint to be attached
by various means to the broken limb. The ratchet, which is revolved by means
of a thumb-plate or lever, is secured at any desired point by a spring catch.

The apparatus of Dr. Yedder, as we learn by the report of the board of army
surgeons appointed to investigate its merits — which report is attached to this

180

Bibliographical Notice.s.

[July

pamphlet — was recommended to be furnished to each hospital in Washington
and Alexandria, for the purpose of fully testing its value.

This pamphlet contains also a description of an admirable extemporaneous
splint, which has already been proved by experience to be of great service in
enabling wounded men to be transported with comparative comfort. We will
give an account of it by transcribing the description as given by Dr. Foster
Swift, surgeon 8th N. Y. State militia : —

" After the battle of Bull Run, on the 21st of July last, we were left with four
or five cases of fractured arms, with no appliances for their treatment, and with
the prospect of their transportation over a rough road in rough wagons to
Manassas, and thence to Richmond. Without splints, and without any light
material to make them of, I am indebted to Dr. Hoges, of one of the Mississippi
regiments in the rebel army, for the following simple contrivance, which afforded
great relief to our wounded men in their jolting journey. Two strips of adhe-
sive plaster were cut two feet in length and three inches in width, one of which
was carried over the upper fragment to the point of fracture, leaving the loop
above ; the other was carried in a similar manner over the lower fragment,
forming a loop below. A piece of board about one foot longer than the frac-
tured limb, with a Y-shaped piece removed from each end, was then applied to
the arm. The lower loop was tied by a bandage to the lower Y, and the upper
loop to the upper Y. The fragments were thus separated, and the limb could
be secured to the splint by a simple turn of the bandage, above and below the
point of fracture, thus leaving the orifice of the entrance and exit of the ball
open."

In place of the board, the surgeon may use two straight branches of a tree,
of suitable size and length, having a fork at one end, over which the bandage
attached to the loops may be tied. If one branch be let into the other by a
notch before they are bound together, the splint will be firm enough to bear
any pressure.

3. The newly-invented elastic tourniquet, described in the anonymous publi-
cation, placed on the list with the preceding, is the invention of Dr. T. S.
Lambert, of New York.

It certainly is an instrument po'ssessing peculiar advantages, inasmuch as it
only interrupts the flow of blood through the principal arteries of the limb.

The object of this publication is evidently to set forth the advantages of the
employment of this form of tourniquet in military surgery ; and the testimonials
attached declare that " every officer in our army, from the lowest grade to a
general, should have one, and at his leisure moments teach the men of their
regiments how they are to be applied," and that " one should be furnished to
every soldier in the field." These testimonials, it is scarcely necessary to add,
are from, civil practitioners. We do not believe ourselves that if every general
and other officer of the United States army would devote all his leisure time to
teaching how the tourniquet should be applied, and if every soldier in the field
would stop his work to put one on so soon as he felt himself struck, that the
mortality would be appreciably, if at all, diminished, and the disadvantages
attending such proceedings are flagrant.

4. The design of the paper of Mr. Gay on " Intestinal Obstruction by the
Solitary Band" is to aid in the diagnosis, and, consequently, in the treatment
of cases of internal obstruction. Such cases are more frequent than is gene-
rally supposed, for, in the Reports of the Registrar-General for 1855, 420
males and 435 females are said to have died of " obstruction of the bowels,"
independently of deaths from the various forms of hernia. It often happens,
on the post-mortem examination of such cases, that a state of parts is found
which might have been relieved during life by the intervention of the surgeon ;
and one of the most frequent is the presence of a band, forming by its terminal
attachroents a ring into which a portion of intestine has glided and there become
strangulated. From the antecedent history, the mode of attack, and the sensa-
tional, the physical, and the functional indications, Mr. Gay believes that a
reasonable conclusion may be arrived at in regard to the presence of a band as

1862.]

Smith, Handbook of Surgical Operations.

181

the cause of the obstruction. The evidences upon which he lays most stress
are : —

1. An antecedent abdominal affection of such severity as to lead the surgeon
to believe that it might have been attended with some ulcerative or perforative
process of either the bowel or the mesentery. For the repair of these intestinal
injuries, lymph is poured out, and afterwards becomes stretched into a baud,
which may be even twenty inches in length.

2. Suddenness of the attack, without previous visible deterioration of the
patient's health.

3. Pain, first localized, then tenderness over a large area.

4. Distension, with general dulness at first, and subsequent concentration of
dulness and tension towards the original seat of pain.

5. Vomiting, especially if it speedily becomes fecal.

Mr. Gay believes that no such conjunction of symptoms as these can arise
without some sudden alteration in the relation of parts within the abdominal
cavity ; and that in most cases a bridle will be found to be either directly or
indirectly constricting a portion of intestine. So soon as fecal vomiting has set
in, the surgeon is, in his opinion, justified in proceeding to explore the abdomen.

Mr. Gay's paper, of which we have given this slight sketch, is a very
imperfect one, and we regret to see its publication, inasmuch as it is an
evidence of a lack of proper information upon this interesting subject of inter-
nal strangulation of the bowels. While the account given of the pathology
and of the symptoms of this affection are altogether too meagre, nothing
whatever is said as to our means of recognizing the portion of intestine that
may be the seat of obstruction, nor as to the diagnosis of accompanying peri-
tonitis, the existence of which must exert great influence upon the determina-
tion of the surgeon. In the treatment we are only told that it is justifiable to
explore the abdomen, or to open that cavity, and search for the strangulating
band, and divide it, if any be found. No mention is made of the formation of
an artificial anus, which has often been, practised with success in these cases,
and which is an operation applicable to all cases of intestinal obstruction.

W. F. A.

Art. XIX. — HandhooTc of Surgical Operations. By Stephen Smith, M.D.,
Surgeon to Bellevue Hospital. New York : Bailliere Brothers, 1862. 12mo.
pp. 279.

This volume is designed especially for the use of military surgeons, and is
therefore exclusively devoted to the consideration of those branches of operative
surgery which are of most importance in the surgery of war.

It is divided into six chapters, entitled respectively "mmor surgery'' ^' on
the arteries," " on the veins,'' " o?2 amputations," " on resections," and " on gun-
shot wounds."

The second, third, fourth, and fifth chapters, which constitute the great part
of the work, contain an admirable exposition of the subjects to the consideration
of which they are devoted, and they may be consulted by every surgeon with
pleasure and profit.

The chapter on resections is particularly valuable, and it may confidently be
said to contain the best account of this important class of surgical operations
that is to be found in the English language.

The first chapter on minor surgery cannot be regarded as sufficiently full and
complete to fulfil the purpose for which it is designed ; and the last chapter
contains nothing novel, being mainly an abstract of the able article by Prof.
Longmore in " Holmes' Surgery," and with which our readers are already ac-
quainted.

The book is published in a very convenient and portable form, and the text
is abundantly illustrated by engravings judiciously selected from the most ap-
proved works on operative surgery. W. F. A.

182

Bibliographical Notices.

[July

Aet. XX. — Transactions of the Obstetrical Society of London. Yol. III.
8vo. pp. 480. London, 1862.

The present volume, whicli comprises the Transactions of the society for the
year 1861, does not in the slightest degree fall behind the two preceding ones
either in the interest or value of its contents. Besides the President's Annual
Address, it contains thirty-nine papers — chiefly reports of cases, or practical
remarks on questions of importance in reference to obstetrics, or certain of the
diseases of women and children. An abstract of several of these papers has
already been presented to our readers in our quarterly summaries of the pro-
gress of medical knowledge since the first of January of the past year. Of the
remaining papers we shall proceed to present to our readers a short notice.

The address of the President, Dr. W. Tyler Smith, is occupied, mainly, by a
biographical sketch of Dr. Edward Rigby, who, for the first two years of the
society's existence, filled the presidential chair with great ability, and so much
to the satisfaction of the members, that, at the annual meeting held on the very
day his remains were consigned to the tomb, they had intended to suspend the
operation of the law which limits the tenure of office to two years,' in order that
they might, as a mark of their high respect and approbation, elect him for the
third time as their chief.

Case of Fibrous Tumour of the Uterus. By T. H. Tanner, M.D., etc. — The
patient was thirty-four years of age, of fine appearance, tall, and very stout.
Had been married seven years. Supposed herself to have been, but, probably,
without any foundation, twice pregnant, and on both occasions to have miscar-
ried at the end of a few weeks. Had enjoyed good health to within a few years
before her death. She first noticed that her catamenial discharge became much
more profuse than usual. She had then for many months occasional floodings,
which gradually became more frequent, and, finally, were replaced by a con-
tinued hemorrhage from the uterus, which rendered the patient weak and exsan-
guine. In the beginning of June, 1855, she applied to Dr. Tanner for medical
aid. She was then feeble, and nervous, with loathing of food, a weak pulse, and
frequent attacks of palpitation of the heart. By auscultation of the latter organ,
a systolic, anaemic, bellows sound was detected, while a venous bruit was heard
in the neck. Parietes of abdomen so loaded with fat as to prevent the condi-
tion of the viscera within being detected. There was greater dulness over the
hypogastric region than elsewhere, with a sense of resistance as from a solid
tumour. Examination per vaginam showed that the cervix uteri was very
high up, and the os very small, so as not to admit the passage of a small bougie.

The diagnosis made by Dr. T. was the existence of a small foreign body of
some kind in the uterus, and a tumour, probably ovarian or uterine, occupying
the lower portion of the abdomen.

The patient was directed to keep quiet in bed, to take plenty of nourishment
and stimulants, and twenty grains of ergot, every six hours. Under this treat-
ment she slowly improved ; at the end of about ten days the bleeding ceased.
Quinine and acid mixture were then given, with a full animal diet, and she went on
until the catamenia again appeared on the 9th of July. Astringents were imme-
diately commenced with, and the discharge ceased in ten days.

From this time until the patient's death, December 28, 1860, the hemorrhage
recurred at every catamenial period, and was checked with great difficulty.
Astringents of every kind, ergot, opium, galvanism, the application of ice, in
fact, every remedy reputed beneficial in cases of uterine hemorrhage was fully
tried, but all failed, finally, to produce the slightest good effect. From the irri-
tability of the patient and the morbid sensibility of the vagina an effective plug
could not be endured over twelve hours, even when opium was administered to
diminish the uneasiness. The only remedy which had any eff'ect in checking the
hem.orrhage was mercury, and to it the patient owed her life on several occa-
sions. Its good effects were equally obtained whether the bichloride was given
in doses of the sixteenth of a grain every six hours, or calomel administered to
the extent of producing ptyalism.

1862.] Transactions of the Obstetrical Society of London. 183

During the last quarter of 1860 the patient became extremely exhausted, and
suffered much from irritability of stomach, by which she was prevented, for
several days at a time, from taking anything by the mouth. Without losing flesh,
she became weaker and weaker, and, finally, sunk from pure anaemia.

After death the body was found quite bloodless. The adipose tissue on the
abdominal walls was two inches thick, while the vaginal labia looked like large
folds of fat. The lower part of the abdomen was occupied by an oval cyst nearly
nine inches broad, apparently formed beneath the peritoneum stretched upwards
from the fundus uteri; it contained about a pint and a half of urinous looking
fluid. A smaller cyst was also present containing two drachms of serum. The
large cyst rested upon the expanded wings of the iliac bones and kept the uterus
out of the true pelvis. The cavity of the uterus was found to contain a fibrous
tumour, about the size of a small orange cut in two. It was attached, by its
base or broadest part to the posterior wall of the uterus, and projected fully
three-quarters of an inch into the uterine cavity. The other organs of the body
were healthy.

The larger cyst had probably commenced in the right broad ligament, which,
with the Fallopian tube, it had gradually distended. The left Fallopian tube
was dilated, and contained pus — not, apparently, of recent formation.

Ovariotomy, with Cases and Remarks on the Different Steps of the Opera-
tion, and the Causes of its Mortality. By W. Tyler Smith, M. D., etc. — Four
cases are related in which ovariotomy was performed by Dr. Smith, in all
with a favourable result. The cases, we are assured, were in no way selected ;
two of them were unfavourable cases — one being of the worst form of ovarian
disease, that which most nearly approaches to the character of malignancy.
They are the only cases in which he has ever attempted anything beyond tapping
with or without injection of iodine ; and never before could he point to an equal
number of distinct and positive cures of ovarian disease.

In a table compiled by Mr. Clay, showing the special causes of mortality in
150 cases of ovariotomy, 17 per cent, of the fatal cases occurred from shock or
collapse produced by the operation. This source of fatality Dr. S. proposes to
avoid by a more early resort to the operation. This would lessen, also, the
number of cases of adhesion between the ovarian cyst and other organs. Ex-
cepting in cases where this adhesion is intimate and extensive he can see nothing
necessarily belonging to the operation, which, with the use of chloroform, should
produce a dangerous shock.

According to the same table 16 per cent, of the fatal cases were due to hemor-
rhage. All, or nearly all of these, according to Dr. S., should have been pre-
vented by care in the application of the ligature to the pedicle, and in securing
hemorrhage connected with adhesions. One source of hemorrhage has been
the use of the ligature without transfixing the pedicle. Dividing the pedicle
too near the ligature is another source of danger, by allowing the ligature to
slip over the stump.

Not less than 43 per cent, of the fatal cases are credited to peritonitis. Dr.
S. believes that the occurrence of peritonitis does not depend so much upon
anything connected with the operation itself as upon miasmatic or contagious
influences. Hence the greater fatality of the operation in hospitals than in
private practice.

The remaining causes of fatality are of minor importance and of unfrequent
occurrence. The three causes, shock, hemorrhage, and peritonitis, represent
upwards of 75 per cent, of the total deaths after ovariotomy; all of them,
according to Dr. S., with proper care may be in a great measure obviated.

Case of Defective Formation of Skin round the Umbilicus. By Albert
Napper, Esq. — A new-born, healthy-looking boy, had on each foot a supernu-
merary great toe ; on each hand a small additional finger, attached by a thin
peduncle to the middle joint of the little finger. The thumbs were very broad
with a depression down the centre, giving an appearance as if they were double.
Some of the fingers and toes were webbed. Besides these deformities there was
a deficiency of the integument at the umbilicus, permitting the contents of the
abdomen to protrude into the umbilical cord to the size of a small orange.
When the cord sloughed ofi", which it did at the margin of the true skin, it

184

Bibliographical Xotices.

[July

left only a thin transparent membrane covering the hernia, which latter daily
increased in size until it measured seven and three-quarter inches in circumfer-
ence. On the twelfth day after the birth of the child an attempt was made to
close the opening at the umbilicus by a plastic operation. A circular incision
was performed through the skin around the edge of the tumour, exposing the
peritoneal covering. In endeavouring to separate a small portion of the mem-
brane which firmly adhered to the peritoneum, the whole contents of the abdo-
men, with the liver (the left lobe of which was adherent to the apex of the
tumour) , escaped, and were returned with great difficulty. The edges of the
wound were brought into contact by means of needles and the figure of eight
sutures.

The child did not appear to suffer much from pain or exhaustion. It took
milk and water at intervals — the mother having lost her milk the previous day.
It lay in a composed state until two o'clock the following morning, about twelve
hours after the operation, when it died.

The operation in this case was solely justifiable, as offering the only chance of
saving the infant's life. From the rapid increase of the hernia there was cause
to fear that the membrane would quickly slough and permit the escape of the
abdominal contents.

Fibrous Tumours of the Uterus treated by Surgical Means. By I. Baker
Brown, F. R. C. S. — Six cases are related, with an account of the surgical treat-
ment. These cases were, in all instances, examples of non-pedunculated tumours,
and were destroyed by cutting into and destroying a portion of their tissue ; in
other words, by gouging out a portion of them. But one of the cases terminated
fatally, in consequence, as Mr. B. supposes, of the introduction of pus into the
circulation through one of the recently divided surfaces. To avoid such an
occurrence in future, he, as a general rule, divides the operation into two parts.
The first, division of the os and cervix uteri; the second, performed when the
preliminary incisions have healed, cutting into the tumour with a view to excit-
ing in it suppuration.

The instrument employed by Mr. B. resembles an ordinary centre-bit twisted
spirally, with various cutting ends. There being a difficulty of fixing the tumour
with such an instrument, Mr. P. Harper proposes one consisting of a hollow
steel tube, with cutting knives. Within the tube is a hook capable of being
protruded by a spring so as to seize the tumour, whilst the circular knives are
carried through by means of a screw, actually cutting out a piece of the tumour.
The instrument is graduated, in order that by measuring the tumour from with-
out, a tolerably correct idea may be formed as to how far the tumour is cut into.

On Uterine Hoimatocele. By Henry Madge, M, D. — This paper gives a very
excellent summary of the leading facts known in relation to this form of hemor-
rhage, gleaned chiefly from the French and German writers on the subject. A
case is related which happened in his own practice as an example of true "retro-
uterine hsematocele." The case terminated fatally, and the appearances on dis-
section- are detailed, and coloured drawings given of the parts involved.

This case was marked by certain peculiarities, which are thus indicated by Dr.
Madge : —

"1st. The double attack at the commencement of the illness, the slight peri-
toneal mischief, and partial recovery, followed by the severer symptoms and
protracted sufferings. Now, it seems quite possible that, if other conditions
had been favourable, and the patient had not attempted to get about too sSon
after the first attack, everything would have gone well." —

"2d. The absence of 'tenesmus' and of 'a frequent desire to pass water.'
The absence of tenesmus might, perhaps, receive an explanation in the proba-
bility that the pelvic tumour did not descend low enough on the rectum to call
that symptom into existence. With regard to the bladder, as the patient always
kept the recumbent posture it is not difficult to understand how the neck might
have escaped the amount of pressure necessary to cause irritability." —

" 3d. The absence of ' fluctuation' in the tumour. The pelvic or lower portion
of the tumour was at first hard and unyielding, and after being emptied of some
of its contents it became rather soft and flabby." —

"4th. The absence of arterial pulsations from enlarged arteries surrounding

1862.]

Transactions of the Obstetrical Society of London.

185

the tumour." The presence of these pulsations has often been observed, but
not invariably.

" 5th. The presence of phlegmasia dolens." This must be viewed as an ex-
ceeding rare complication of uterine hsematocele. " When it does happen," Dr.
M. thinks " it may, perhaps, be regarded as an evidence that pus in considerable
quantity has been formed within the tumour, or that the blood contained in it
has undergone changes of an unhealthy character, leading to phlebitis, from its
absorption by the veins."

Case of Difficult Position of the Heads during Tiuin Laborer. By T. Pol-
lock, M.D.— A lady 25 years old, apparently well formed, at full term of first
pregnancy, was seized with labour pains about 2 o'clock A.M., February 21st,
1861. At 9 o'clock, edge of os uteri very thin, but the os itself undilated ; a
tumour of flat bones felt presenting. By 7 o'clock P. M. the os uteri was
dilated to the size of a half-crown piece, the presenting part descending into the
hollow of the sacrum ; the advancing part could not be accurately made out.
In addition to the loose flat bones, some sharp points between them, and some-
thing resembling the coccyx, could be distinguished. Three hours later the
finger thrust through the membranes discovered an anus, but no nates. Soon
afterwards the right thigh and leg were brought down, and then the left. On
making the proper traction during the pains to accomplish the delivery, Dr. P.
found his efforts resisted by some elastic, counteracting force, causing a constant
tendency in the body to recede so soon as the traction was discontinued. At
length a head began gradually to pass through the vagina and out at the external
parts ; but, much to Dr. P.'s surprise, it proved to be the head of another child.
The head of the first child was extracted in a few minutes without much diffi-
culty. It was found that the lower jaw of the extracted child lay across the
lower jaw of the one unborn, so that the side of the face and head of the one
pressed on the throat and upper part of the chest of the other. Hence, the
first child dragged the second down, while the second held the first back, pro-
ducing the elastic resistance referred to..

The second child was soon afterwards entirely expelled, and the placenta
promptly followed. Both children — boys — were born dead. The mother did
well, not experiencing a single unfavourable symptom.

Presentation of Right Shoulder and Arm — Spontaneous Evolution. By
Charles Mayo, F. E. 0. S. — After a labour of some two days, the right arm
was found presenting, with the shoulder forced down. In consequence of the
powerful contraction of the womb upon the child, the several attempts at turn-
ing were unsuccessful, notwithstanding the free use of opiates and the inhalation
of chloroform. After the lapse of several hours, the pains increased in violence,
and the breech of the child — a boy — was expelled, speedily followed by the feet.
An hour subsequently the head and left arm came away. The child was, of
course, dead and exsanguine as it were from compression, excepting the right
arrii and shoulder, which were deeply discoloured and swollen. There were
severe after-pains and the passage of considerable clots. AVith good care and
nursing the patient recovered slowly ; had little or no trouble with her breasts.

On the Indications and Operations for the Induction of Premature Labour,
and for the Acceleration of Labour. By Robert Barnes,- M. D. — In this very
able paper Dr. Barnes has given a full history of the several means which
have, at different times, been proposed for the artificial induction of labour, and
for its acceleration in cases where this result is desirable and admissible. He
has attempted an exposition of their respective and relative merits, while he
indicates the particular cases and circumstances in which their employment
may be resorted to with a fair prospect of their yielding beneficial results. Dr.
Barnes' paper will be read by every one engaged in obstetrical practice with the
deepest interest. Nowhere can there be obtained a more full and practical view
of the subjects discussed. We regret that we shall be able to present only the
general summary with which the paper closes.

"It may be stated, as a general fact, that all the means employed in the in-
duction of labour act by stimulating the spinal centre to exert itself in causing
contraction of the uterus. Some of these agents act directly upon the spinal
marrow, being carried thither in the blood, such as ergot of rye, borax, cinna-

186

Bibliographical Notices.

[July

mon, and other drugs. Some evoke the energies of the diastolic system, by
stimulating various peripheral nerves, such as rectal injections, the vaginal
douche, the colpeurynter, the carbonic acid gas douche, probably the irritation
of the breasts by sinapisms and the air-pump, the cervical plug, whether in the
form of sponge tent or the caoutchouc dilator, the separation of the membranes,
the placing of a flexible bougie in the uterus, the intra-uterine injection, the
evacuation of the liquor amnii, and galvanism. The artificial dilatation of the
cervix, the evacuation of the liquor amnii, and the intra-uterine injection act in
a more complicated manner, and not simply through the diastolic system.

" Regarded from a therapeutical point of view, or in their application to
practice, labour-inducing agents have been divided into — A. Those in which
the integrity of the ovum is respected to the last; B. Those in which the ovum
is interfered with, either by puncture or by partial detachment from the uterus.
I would propose the following as a more scientific and more instructive classifi-
cation: A. Preparatory measures ; B. Labour-provocative measures ; C. Labour-
accelerating measures.

" I attach great importance to this arrangement, because I believe that in the
majority of instances it is desirable not to trust to any single agent or method,
but to proceed in regular gradation through the stages of preparation of the
system, and of the passages concerned in parturition, the evocation of the con-
tractile energies of the uterus, and the acceleration of delivery, selecting such
means in each stage as are most suitable. I believe that much danger to the
child, and some risk to the mother, may be avoided by duly preparing the vagina
and cervix uteri by partial dilatation and softening through the agency of the
colpeurynter and the cervical plug. These, although they will sooner or later
act as provocatives of labour, are chiefly efficient as dilators of the passages.
The stage of preparation completed, we may endeavour to excite uterine con-
traction by the vaginal douche, by rectal injections, by the partial detachment
of the membranes from the lower part of the uterus, by the exhibition of purga-
tives. The ergot I am inclined to discard, and know that it can be dispensed
with.

" If the labour hangs, if the pains are difficult to evoke, there is no necessity
to abandon the patient to the tortures of suspense or the risk of accidents. We
have in reserve the accelerative measures, which, the soft parts being duly pre-
pared, place the termination of parturition entirely within our control. We
may resort to abdominal frictions, the binder to support the uterus firmly against
the spine, the larger uterine dilators, which are made to expand inside the cervix
and to press, after the manner of the tense amniotic sac, upon the os internum
uteri, the most active seat of excitation of the parturient energy ; the rupture of
the membranes, an operation free from all objection if performed just prior to
the natural or artificial termination of labour ; and, lastly, we have the opera-
tion of extraction after turning by combined internal and external manipulation,
without passing the hand into the uterus. By the judicious consecutive use of
these means we have it in our power to terminate a labour not only on a fixed
day, but almost at a predetermined hour, and that with a greater amount of ease
and security to the mother and child than has been hitherto obtained."

Substitute for Brandy in Cases of Exhaustion — Br. BruitVs " Liquid
Essence of Beef' — Lean beef, minced and then inclosed in a jar, and subjected
to heat for an hour or more, separates into fat, fibre, and liquid essence. The
last, being strained off, and the fat removed by means of blotting paper, is a
clear amber liquid, of an intensely aromatic smell and taste, very stimulating to
the brain. It is not intended as a substitute for common beef-tea, or common
broths and soups, but as an auxiliary to and partial substitute for brandy in all
cases of great exhaustion or weakness, attended with cerebral depression or de-
spondency. In the sequelae of severe and exhausting labour it is invaluable.

Case of Idiopathic Pericarditis in a Child two years old. By A. Meadows,
M.D. — The child had been labouring for a few days under some degree of fever-
ishnes5, and for a few hours before death there was noticed difficulty of breath-
ing, with a short, hacking cough, but no indications of rheumatism. Death was
preceded by convulsions. Dissection showed inflammation of the pericardium,

1862.]

Transactions of the Obstetrical Society of London.

187

both layers of which were covered with delicate, soft flakes of recent lymph
there was also a little fluid effused into the pericardial sac.

New Pelvimeter. Invented by L. Lumley Earle, M. D. — The instrument is a
very ingenious one, and in many respects is superior to any of those which
have been heretofore suggested. From a mere description, without a drawing
of the instrument, its construction would not be understood.

Smallpox in Twin Foetuses. By Henry Madge, M. D. — A lady, nearly four
months advanced in pregnancy, was attacked with varioloid ; not very severe or
attended with any great amount of eruption. Three months afterwards she was
delivered prematurely of twins. The first foetus expelled (a male) was the
smaller; the other (a female), born after an interval of about fifteen minutes,
was much larger, and in some of its parts better developed. Both were affected
with smallpox. The largest presented the most extensive eruption of true vario-
lous pustules, varying in size, with central depression. The male foetus had but
six pustules on its body. They were small but perfect in form. The twins were
born dead, but it was evident that life had not been long extinguished.

The foregoing and other cases on record would seem, Dr. M. thinks, to
prove : —

" 1st. The independent liability of the foetus to disease, as shown by the different
type of smallpox it may experience to that experienced by the mother, and in
cases of twins in utero affected with eruptive disease, the much greater develop-
ment of the disease in one than in the other, and, further, the possibility of only
one being affected.

"2d. The nature, or rather the extent of the protective power of vaccination
in adults.

3. The necessity or advisability of recommending all pregnant women, during
epidemics of smallpox, or when residing in or near a district where the disease
is prevalent, to be vaccinated or revaccinated, so as to extend the protective
influence of vaccination to the child in utero."

Idiopathic Pericarditis in a Child tivo and a half years old. By Henry
Mayo, M. D. — The child died rather suddenly, without apparently suffering pain.
The pericardium was distended with about four ounces of yellowish serum con-
taining flakes of lymph, the heart was imbedded in a dense layer of the inflam-
matory product.

Case of Hydatid Mole expelled from the Uterus immediately after a Living
Foetus and its Placenta, at about six months gestation, the hydatid growth
being the degenerated ovum of a twin conception. By J. Hall Davis, M. D. —
The main interest of this case is fully expressed in the title just recited of the
paper containing its history. The remarks of Dr. Davis which accompany his
history will fully repay an attentive perusal.

Unusual Elongation of the Foetal Head, as a cause of difficidty in the appli-
cation of the ordinary Obstetric Forceps, with description of a modified form
of instrument to be used in such cases. By G. Hewitt, M. D. — Besides the
elongation of the foetal head in its occipito-mental diameter, when it has passed
through a pelvis of very small dimensions, or when the soft parts connected with
it are unusually rigid, there is a change in its shape causing it to resemble rather
the segment of a cylinder rounded off at the two extremities, than its natural
ovoid form. This change in the foetal head renders the ordinary obstetrical
forceps difficult of application, from a want of correspondence between their
curve and that of the head. Dr. Hewitt has constructed an instrument adapted,
as he believes, to such cases — a drawing of which accompanies his paper. The
blades have a length of eight inches, and the curve an arc of a circle of fourteen
inches in diameter. It is consequently, when locked, fitted- to inclose a larger
oval than the ordinary English forceps.

Inflammation of the Breast, and Milk Abscess, ivith an analysis of seventy-
two cases. By T. W. Nunn, F. R. C.S. — Of the fifty-eight lactating cases in-
cluded in the list of cases of mammary inflammation given by Mr. Nunn, 33, or
between 56 and 57 per cent., occurred during the first two months after delivery;
during the seven subsequent months up to the ninth month inclusive, only 8
cases, or 14 per cent.; after the ninth month 17 cases, or 29 per cent. There-
fore, if the liability to inflammation during the first two months be represented

188

Bibliographical Notices.

[July

by 4, then as far as Mr. N.'s observations go. the liability during the following
seven months collectively falls to 1, and for the period after the ninth month
rises to 2. This proclivity to inflammation after the ninth month must, accord-
ing to Mr. N.. be considered as an induced proclivity, having its origin in a
certain condition — a special cachexia — brought about by over-lactation.

From his analysis of cases, Mr. N. has ascertained that the lower segment of
the breast, compared to the other parts of the gland, has nearly double the
liability to intense inflammation.

In respect to certain points connected with the treatment of mammary inflam-
mation and suppuration, Mr. N. presents some remarks which deserve attention.

Poultices. — Their continued use from day to day — week after week — he con-
demns as mischievous, and a hinderance to recovery. Under ordinary circum-
stances he believes cotton soaked in oil. or fine lint spread with resinous oint-
ment, to be the preferable application, both as a remedial means and from its
being free from the disagreeableness of poulticing.

The recumbent position Mr. N. believes may be rationally insisted upon, from
the consideration of the fact of the more frequent occurrence of abscess in the
lower lobes of the mammary gland.

Belladonna as an ointment Mr. N. has employed on many occasions, but
without any encouraging results. Several patients under its use complained of
an increase of pain.

As to the time proper for opening a mammary abscess, a too early and free
incision involves excess of pain and hemorrhage, while delay beyond a certain
point risks the sloughing of the integument and the torture"^ from spontaneous
perforation.

From the pain caused by any attempt to detect fluctuation by the ordinary
manipulation in cases of inflamed mamma, Mr. N. trusts to these indications
aff'orded to the eye alone — the protuberance and tension, the glazed surface and
peculiar colour of the skin over the seat of the abscess.

In the treatment of the sequelse of mammary abscess, in sinus of the breast,
and the painful oedema so apt to remain after the more acute phenomena of in-
flammation have subsided, a weak galvanic current, such as is aff'orded by the
single cell apparatus in ordinary use for administering the interrupted current,
he has found eminently beneficial.

The three following cases are interesting and proper to be recorded, but pre-
sent no features of particular importance in respect to diagnosis or practice.
They are — one of Fibroid Tumour springing from the Posterior Lip of the
Uterus, causing Complete Prolapse, and simulating Inversion of the Uterus.
By Robert Barnes, M. D. One of Glandular Cystic Tumour of the Mamma.
By Mr. Squire. One of Ovarian Tumour removed by Ovariotomy. By Mr.
Spencer Wells.

Four Cases of Ovariotomy. By "W. Tyler Smith, M. D. — The history of
these four cases is intended as an appendix to the paper read at a former
meeting of the society and already noticed. Three of the cases terminated
favourably.

Pelvic Cellulitis after Second Pregnancy, followed by Suppuration in the
Left Groin and Left Antero-Superior Femoral Region. By N. C. Hatherly,
M. D. — A female, twenty-nine years old, of leuco-phlegmatic appearance ; mar-
ried for seven years; delivered of her second child September 8, 1858. Her
labour was easy and speedy, and her getting up favourable. About five weeks
after confinement she experienced an inability to walk from increasing stiffness
and slight pain of left groin and left abdominal region — nothing unusual could
be detected upon examination. In a few days afterwards there was difficult
and somewhat painful micturition. The only constitutional symptom was a
very antemic appearance. She was ordered poppyhead stupes with anodyne
poultices; an occasional Dover's powder at night, with quinine and iron during
the day.

Dec. 5th. Slight fulness above the centre of Poupart's ligament of left side,
of doughy feel, not easily defined ; not over tender, complains of some pelvic
fulness. Vaginal examination showed only unusual sensitiveness of canal.
Bigors eventually set in, and suppuration gradually advanced. Tumour in-

1862.] Transactions of tlie Obstetrical Society of London. 189

creased in size and became acuminated. Considerable irritative fever. Secre-
tion of milk had gradually ceased. On the 20th, a valvular opening was made,
which gave discharge to twelve ounces of healthy pus. On the 25th, the dis-
charge "suddenly ceased, and pain set in in the upper left femoral region opposite
the saphenous opening. On examination it was evident a fluid was collecting
there ; the tumour rapidly increased, spreading downwards and laterally. Jan. 1.
By a valvular opening in the most depending part the pus was partially evacuated.
Ordinary treatment pursued. 5th. Symptoms of pyaemia; pulse very feeble,
averaging 130 in a minute ; nausea and great prostration. At the end of three
days patient began to rally — discharge decreased— daily improvement under
use of very generous diet, alcoholic stimulants, tinct. ferri sesquichlor. and
quinine.

The wound healed in about a month ; at the end of twelve weeks went out
for a drive — continued to progress steadily. Catamenia reappeared in the fourth
month. Considerable stiffness of the hip-joint remained for nearly six months,
when she was again able to walk about pretty well. She became again pregnant
in about twelve months, and was safely and easily delivered of a fine child, and
recovered without any untoward symptom.

Historical Notes on DispIacemeTit of the U^izmpregnated Uterus as a Cause
of Displacement of the Gravid Uterus. By J. H. Avelixg, M.D.— Dr. A.
attempts to show that the fact of displacement of the pregnant uterus being the
result of a similar condition of the non-pregnant organ was known to ]\[orgagni,
and was pointed out by him more than a century ago ; and that since his time
it has been adverted to by several members of the profession without their being
aware, seemingly, that it had been previously noticed by any medical writer.

When the paper was read before the society Dr. Tyler Smith remarked that,
with the exception of Dr. Aveling's quotations from his paper of November,
1860, those from every other writer referred entirely to the different forms of
lateral obliquity of the pregnant uterus. Only one of the authors cited spoke at
all of retroflexion, and that in a purely speculative manner. Dr. Smith's view,
as opposed to that of William Hunter, that retroversion of the gravid uterus was
caused by the impregnation and development of the previously retroverted organ,
was published in 1856, and, he remarked, it has not been shown that this fact
was understood by any previous writer.

The Influence of Abnormal Parturition, Difficidt Labours, Premature Birth,
and Asphyxia Neonatorum on the Mental and Physical Condition of the Child
especially in Relcdion to Deformities. By W. J. Little, M.D. — The deformity
to which Dr. L. especially refers, and an exposition of the pathology of which
is the chief object of the present paper, consists in a tonic rigidity and ultimate
structural shortening, of varying degrees, in a few or many of the muscles of
the body. Both lower extremities are more or less generally involved. The
muscles of the neck, upper extremities, and trunk, may be affected either singly
or - several of them at one and the same time.

Dr. L. presents in tabular form an analysis of sixty-three cases of children, of
whom forty-seven were affected with spastic rigidity, chiefly of the muscles of
the extremities, after abnormal or premature labour, or congenital asphyxia ;
two with wry neck from abnormal labour or congenital asphyxia ; five with
spastic rigidity, suspected to be from asphyxia neonatorum ; four with muscular
debility, or paralysis from abnormal or premature labour or asphyxia ; two with
convulsions from asphyxia at birth, followed by paralysis ; one with imbecility
from congenital asphyxia : and one with spastic rigidity and imbecility from, it
is supposed, embarrassed breathing ; while of one case the post-mortem exami-
nation is given to illustrate the production of apoplectic capillary congestion in
a child born without pelvic obstruction at birth.

Doubtless, Dr. L. admits, there was in some of the cases he has recorded suf-
ficient mechanical injury to the head and neck inflicted to account for whatever
unfavourable consequences, whether these were fatal or not, may have ensued ;
but he is convinced, the more the facts he has adduced are studied the more
apparent will it be that a larger proportion of infants, either dead, still-born,
apoplectic, or asphyxiated at birth, have been rendered so by interruption of
the proper placental relation of the foetus to the mother, and non-substitution

190

Bibliographical Notices.

[July

of pulmonary respiration than from direct mechanical injury to the brain and
spinal cord. Dissection has shown the important fact that mechanical injury
of the foetus is not necessary for the production of intense congestion and blood
extravasation of the serous surfaces of chest, brain, and spinal cord.

" The other phenomenon commonly observed in difficult and abnormal partu-
rition is that of interruption of placental respiration and circulation with non-
substitution of pulmonary breathing and circulation. To this phenomenon
alone, when mechanical injury or impediment has not existed, can we attribute
the internal congestions, capillary extravasations, serous effusions which cor-
respond with or produce the symptoms of asphyxia, suspended animation, apo-
plexy, torpidity, tetanic spasms, convulsions of new-born children, and the spastic
rigidity, paralysis, and idiocy subsequently witnessed."

The paper of Dr. Little is a very valuable one ; he has handled his subject
very fully and with great ability. It must be received as an important contribu-
tion to infantile pathology.

New Instruments for the Removal of Uterine Polypi, ^c. By J. Braxton
Hicks, M. D. — The principle of these instruments is the application of annealed
steel wire to a modification of the screw ecraseur. They may be considered as
a decided improvement on the instruments in common use. Their construction
and the mode of using them will be readily understood by the description given
by Dr. H. in connection with the drawing that accompanies it.

Polypus of the Uterus, Pendulous in the Vagina, removed by the Ecraseur.
By G. Hewitt, M. D. — The interest of this case arises from the fact that its real
nature had been for a long time misunderstood — it being taken for a falling of
the womb — and the patient, in consequence, subjected to a futile and erroneous
method of treatment. The pedicle of the polypus was found, after removal, to
be about half an inch thick. The only inconvenience experienced by the patient
during the removal of the tumour was just at the last, when a severe pain was
complained of, due, as it appeared, to the traction of the pedicle on the wall of
the uterus. There was no hemorrhage, and the patient made a perfect recovery.

Five Cases of Ovariotomy. By I. Baker Brown, Esq., F. R. C. S. — These
cases make a total of fourteen operations for ovariotomy performed in the
London Surgical Home, of which ten have been successful.

Female Bladder showing the Results of Retention of Urine after Delivery.
By T. Spencer Wells, Esq., F. R. C. S. — The patient, 22 years of age, was de-
livered of her first child August 20. 1860. Retention of urine ensued, to which no
attention was paid for two days, when an unsuccessful attempt was made to pass
the catheter. Twenty-four hours afterwards five pints of turbid, bloody urine
were drawn off. The catheter was now introduced two or three times a day for
some time. The urine became ammoniacal, and remained so. Involuntary
dribbling of urine, without any fistulous opening, set in in the beginning of
September, and, after a train of very distressing cerebral symptoms, the patient
died October I6th.

After death the coats of the bladder were found thickened and lying loose in the
cavity. It contained a mass composed of the entire mucous membrane detached
from the muscular coat, and covered on both sides with a deposit of urinary salts.
Microscopically this mass might be described as degenerate epithelium holding
a saline deposit. On boiling a piece of it in twenty pints of water to one ounce
of acetic acid, much of the saline matter was dissolved, and some of the tissue
became clear, having the appearance of smooth muscular tissue which has begun
to degenerate by the deposit of fatty or albuminous particles in its substance.

On Vaginismus. By J. Marion Sims, M.D. — By the term vaginismus Dr. Sims
proposes to designate an involuntary spasmodic closure of the mouth of the vagina,
attended with such an excessive supersensitiveness as to form a complete barrier
to coition. The most perfect examples of vaginismus Dr. S. has met with were
uncomplicated with inflammation. He has met, however, with cases in which
there was a slight redness or erythema at the fourchette, just without the re-
duplicature of the vaginal mucous membrane called the hymen. The latter is
usually thick and voluminous, and when the finger is passed into the vagina its
free edge often feels as resistant as if bound with a fine cord or wire. The
gentlest touch with the finger, or even a feather, produces the most excruciating

1862.] Transactions of the Obstetrical Society of London. 191

agony. The sensitiveness which is at all parts of the vaginal outlet, is especially
pronounced at the meatus urinarius and on each side of it, still more so on the
outer face of the hymen, near the orifice of the vulvo-vaginal gland, and to the
greatest extent just in the sulcus or reduplication from the vulval orifice. In all
cases the mere spasm of the sphincter is painful, and in many cases the sphincter
ani feels almost as hard as a ball of ivory. The spasm is pathognomonic of the
disease, the supersensitiveness diagnostic.

The treatment proposed by Dr. S. consists in the removal of the hymen, the
incision of the vaginal orifice, and its subsequent dilatation. For a description
of the operation and of the instrument employed by him as a dilator, we must
refer to the paper itself.

Case of a Patient who in Eighteen Pregnancies gave Birth to only Seven
Ldving Children, the eleven others having been expelled dead at various periods
of Gestation. By W. Newman, M. D. The circumstances connected with this
case would seem to point very clearly to a cause of death in the foetus that has
been too frequently overlooked, namely a want of formative power on the part
of the mother, which in the case detailed increased with each succeeding preg-
nancy.

Case of Abortion : Retention of Ovum within the Uterus, and Growth of
Membranes for a Period of Five Months after the Death of the Foetus. By
G. Hewitt, M. D.

Knot on Funis, in a Case in ivhich the Foetus ivas horn dead. By W.
Sankey, Esq. — The titles of these two papers explain fully the leading character
of the cases described in them.

Instrument for the Removal of Polypi of the Uterus. By Tyler Smith, M. D.
— It consists of a rod and winch with double canula, made sufficiently strong to
carry a single or stranded copper or iron wire, and bear tension enough to cut
through the neck of a polypus at once.

Case of United Children, or Double Monstrosity. By Henry Hawks,
L. R. C. P. Ed. — The heads of the children were covered with hair. Each of
them possessed two arms and two legs, with perfect fingers and toes. There
was a single thorax, in which were two lungs, one pericardium, and one heart. The
abdomen was common to both children, with a single liver and spleen, one set
of intestines, and two kidneys. There were two urinary bladders. The union
of the child was from the top of the sternum to the umbilicus. The length of
one was eighteen inches, of the other seventeen inches ; they measured eighteen
and a half inches round the shoulders ; weight sixteen and a half pounds.
They appear to have been both females.

Case of Peritonitis caused by Escape of Pus or Putrilage from the Fallopian
Tube into the Abdominal Cavity, folloioing an Abortion artificially induced.
By Robert Barnes, M. D. — This case, with the introductory notice of cases of
a similar character, is replete with interest. It will not admit well of abridge-
me-nt, and this article has been already extended to too great a length to admit
of its insertion entire.

A very valuable practical paper is presented by Mr. Robert Ellis, on Cau-
terization by Electric Heat in certain Diseases of Women, to which we would
call special attention. The subject is a most interesting one, and is ably
handl'ed by Mr. Ellis.

Case of Inguinal Hernia of the Right Ovary successfully removed. By A.
Meadows, M. D. — Cases of a similar character are extremely rare. The present
one was among the first in which an operation was attempted. The operation was
in all respects successful. It is suggested that, had the patient been seen when the
accident first occurred, or at least after the first menstrual period, when severe
pain was experienced in the tumour, its nature might even then have been diag-
nosed, and its replacement happily effected either by the taxis or by operation.

The volume closes by the history of a Case of Congenital Inflammatory Dis-
ease of the Skin of the Head and Upper Part of the Body of an Eight Months'
Foetus, ivith Exudation of Plastic Lymph. By G. D. Gibbs, M.D.

D. F. C.

192

Bibliographical Notices.

[July

Art. XXI. — Public Health in Relation to Air and Water. By W. T. Gaird-
NER, M. D., Fellow of the Royal College of Physicians, Edinburgh; Physi-
cian to the Roval Infirmary, and Lecturer on the Practice of ^Medicine. 12nio.
pp. 369. Edinburgh, 1862.

The present volume embraces the substance of a course of lectures delivered
during the summer of 1861, to an audience composed partly of students of medi-
cine, and partly of persons otherwise interested in the subject of public health.
These lectures were undertaken by Dr. Grairdner, mainly to communicate some
of the elementary principles of modern sanitary science to those whom he had
instructed' in the science and the art of healing, in order to complete, as he con-
ceives ought to be completed, the cycle of sciences on which the art of healing
rests ; while, at the same time, he endeavoured to establish a cordial understand-
ing between the medical profession and the community at large on the subject
of public hygiene — to claim for the physician the due influence which he has a
right to exercise in relation to all sanitary reforms, from his legitimate position
as a conservator of the public health, and the labours he has already performed
in respect to its maintenance and increase, and, finally, to effect something
towards establishing the claim which the study of public hygiene presents as a
department of medical science.

Although the arrangement of these lectures and the manner, generally, in
which the subjects embraced in them are handled, may be amenable to criti-
cism, nevertheless, the principles set forth by the lecturer are unquestionably
sound, while his hygienic deductions from those principles are correct and
practical throughout, and of universal applicability. His teachings are based
chiefly upon facts derived from the rich mine furnished by the Registrar General's
reports and those of the Health of Towns Commissions. By a careful collation
of the statistics contained in these reports, compared with those derived from
observations upon the same points collected in some of the larger continental
cities, we are enabled to arrive at certain positive data that have caused modern
sanitary science to pass out from ''the stage of the hypothetical, and become a
strictly inductive and closely reasoned branch of knowledge, resting upon a solid
basis of experience."

Dr. Gairdner was induced to make the consideration of air and water as sani-
tary agents, the leading subject of his lectures on public health, from the fact
that these two essential elements of life, when contaminated with the effete pro-
ducts of the human body, or with organic matter in a state of decomposition,
may be denominated the two factors of almost all endemic and epidemic diseases
as well also of a large number of chronic maladies. Hence, in the manage-
ment of the supply of pure air and pure water is included almost the entire sani-
tary code.

"When," as the lecturer aptly remarks, "you get air and water systematically
purified, you have not only begun, but you have advanced far in the work of
sanitary reform. You have, indeed, done the greater part of all that you can
do in the way of legal interference in regard to public health. It is, therefore,
very important you should thoroughly grasp the ideas connected with the puri-
fication of air and water. The health and the morals of the population here
hang by the same thread ; for though 1 am not about to argue that men are moral
or immoral simply as the creatures of circumstances, yet there can be very little
doubt that the physical circumstances in which men are placed often dominate
to a vast extent their moral health. They do so at all events to this extent,
that without a certain degree of purity of air. water, and person (and the last is
the result of the other two), self-respect, and respect for others, which are the
foundation of the moral code as between man and man. become impossible.
And, therefore, literally and truly, as was said long ago in the way of proverb,
'cleanliness is next to godliness.' Nay, even godliness itself is not a little de-
pendent upon cleanliness when you speak of large numbers of men,"

As the main physiological elements of health Dr. G. enumerates pure air. pure
wholesome water, plenty of light and warmth, good food, sufficient and proper

1862.]

Gairdner, Public Health.

193

clothing, a comfortable home, fitting occ-apation — including in the case of artisans
and mechanics a wholesome condition of workshops — a proper relation between
the sexes — the right cultivation of domestic habits, and of the natural social
affections ; and, finally, a sufficient amount of relaxation and amusement at
proper intervals, including, under the head of relaxation, the important item of
absolute rest and sleep. By quotations from the English health reports Dr. G.
has shown the important relation which these diS'erent conditions of health bear
to one another, and, especially, the immense extent to which "the comfort of
the home and of the workshop, as respects the single first element of health,
proper ventilation, is found to enter into all the more complex developments of
the other essential conditions of health, so that without proper ventilation, and
the closely allied conditions of good drainage and sewerage, it is impossible to
expect that any of the other great vital necessities can be properly or even
moderately well attended to."

Another reason why, in treating of public health, Dr. G. considers that our
chief attention should be directed to a consideration of air and water as sani-
tary agents, is founded upon the circumstance that, to secure to the whole com-
munity and to each individual composing it, a constant supply of these first
reciuisites of health, and in a state of as perfect purity as can be attained, legal
interposition is not only perfectly justifiable but is actually demanded.

" Our food, our clothing, our dwellings — that is to say, the walls and the fur-
niture of them — -are personally ours," the lecturer remarks, "in a sense in which
air and water are not. Air and water belong to no man, they belong to all men.
We have all a right to use them, but we cannot confine the use of them, or even
of any portion of them, to ourselves ; and just because God has given them in
free unstinted measure, as a common gift, to all the inhabitants of the earth
without distinction, just because of this we have all a right to use them, while
none of us has a right to abuse them. And, furthermore, each one of us, as an
individual, and the community as representing the whole mass of individuals, has
an indefeasible right to see that no individual of the community does abuse them
to the possible injury of the rest."

From these premises Dr. G. deduces the right of authoritative interference, if
necessary, in regard to air and water. It may be a question of expediency or of
possibility in any particular case as to how far we can carry that right ; but we
have, he insists, in theory the right, as a community, to interfere to the full
extent necessary to preserve the greatest attainable purity of air and water to
every member of the community.

Dr. Gairdner believes that, from what we know of the history of those dis-
eases which are called epidemic or pestilence, we have a right to conclude their
occurrence is not a necessary or unavoidable thing, but a thing which, by care
and attention to the conditions of health, we can get rid of to a great extent, if
not entirely. We have a right, he maintains, to believe that pestilence may be
rooted out absolutely from the entire community, because we find that in prac-
tice many epidemic diseases have been entirely rooted out in respect to large
sections of the community, by attention simply to the purity of air and water :
and, consequently, that we should not relax our eff"orts until we have got rid
of epidemic diseases entirely. He believes that we are, to a certain extent,
justified by facts in looking upon the mere existence of such diseases — not, per-
haps, in every case, but certainly in the great majority of cases — as the evidence
— plain and undeniable evidence — of a violated law ; a law which requires of us
to abstain from everything that is calculated to detract from the purity and
free circulation of air and water. Impurity and stagnation of these primary
elements of healthful existence being, in his estimate, the main predisposing
cause of all those diseases commonly known as epidemics.

Mere impurity and stagnation of air and water can scarcely, we think, be
viewed as the generating or efficient cause of all afi'ections of an endemic or epi-
demic character. Many of these owe their origin to a certain morbific some-
thing connected with the atmosphere at particular periods, and which more or
less gradually extends itself in certain directions and over different extents of
the earth's surface. Of this morbific principle we know nothing, its presence
being' shown only bv the pestilence to which it gives rise. Now. though it m
jS'O. LXXXYIL— July 1862. 13

194

Bibliographical ^^'otices.

[July

very certain that it may be invited, as it were, to a particular locality or district,
and the intensity of its action augmented by certain appreciable conditions of
atmosphere, including its stagnation and vitiation, yet, in numerous instances,
the influence of the morbific poison will be experienced when the movements of
the air and water are unrestrained and no sources of vitiation in respect to either
can be detected. As Dr. G. well remarks —

''Neither a bad smell, as such, nor sulphuretted hydrogen, as such, nor car-
bonic acid, as such, contains the special poisons which we have to fear particu-
larly as the sources of epidemic disease. But all of these are, to a certain extent,
indications, beneficent, providential warnings plainly given us — to view the
matter from the aspect of final causes — to bring before our very senses the cir-
cumstances under which dangerous poisons may perchance be present. Such
poisons may not be present in ninety-nine cases out of a hundred, where the air
is manifestly impure to the senses, or saturated with gases which are the known
products of organic decomposition, but in the hundredth case you may have a
true morbid poison there present, and then it is a most deadly poison ; and this
we can certainly say, that if we had not had the excess of carbonic acid, nor the
sulphuretted hydrogen, nor the bad smell, in all probability we should not have
had the dangerous element present either. The same law applies to water.
AVater, as I showed you in my first lecture, contains, in some cases,, those morbid
poisons which we have to fear as the causes of disease. It is the medium, for
instance, in some cases, of that dreadful poison of epidemic cholera ; and of some
other diseases it is probably the principal medium. But we can study the pro-
cess most conveniently, perhaps, in the case of the smallpox pustule, which
contains a very terrific poison in small bulk, and so constituted as to act upon
the fluids of the human body by becoming dissolved in water ; or, again, in the
cowpox pustule, which is really only another, though a far more benign form of
smallpox. In these cases we have the whole of the facts in relation to a most
virulent and active source of disease under our daily observation and control.
We know of a certainty, in the little, seemingly insignificant, droplet of watery
fluid inserted into the arm by the inoculator,.is inclosed the specific poison of
smallpox or cowpox. We know, therefore, that such poisons exist, that they
are specific poisons which cannot be chemically analyzed or mechanically weighed
or measured; that an infinitesimally small amoant of them, in fact, will produce
the disease. We know that they may possibly exist wherever water or air con-
tain certain organic impurities, with which the specific secretions or exhalations
of persons suff'ering under disease may have been in contact. We know, on the
other hand, that these poisons cannot exist where there are no such impurities ;
that is nearly all we know about them. And, therefore, although you may not
be able to demonstrate that a particular organic impurity in water is poisonous,
although you may even be able to bring a strong body of evidence to show that
it is not poisonous ; yet, wherever you have a considerable amount of organic
impurity habitually present in water, as in air, depend upon it you have some of
the conditions in which these peculiarly evanescent and dangerous poisons may
possibly lurk unseen."

To impurity of air and water Dr. G. refers, not only as the chief predisposing
cause of epidemic diseases, but as causes, to a large extent, of other diseases.
In proof of this latter position the lecturer confines himself to the etiology of
two diseases, pulmonary consumption and infantile convulsions. The influence
of impure and stagnant air as a cause of convulsions and other serious affections,
by which, annually, in all our larger cities, a very large amount of mortality
among infants is caused, is so well understood by the medical profession in this
country, that it is only necessary here merely to advert to it. The dependence
of pulmonary tuberculosis upon a foul and stagnant atmosphere is, however, not
so generally recognized. That, in conjunction with the want of a due amount
of active exercise, and more especially with a constrained position of body long
continued, it may play an important part in the etiology of tuberculosis is, how-
ever, by no means an improbable supposition.

In the essay of Dr. Baly on the mortality of prisons [Med.-Cliirurg. Trans.,
1845); in the report of the commissioners on the health of the army, appointed
after the Crimean war; and in the reports of the Consumption Hospital at Bromp-

1862.]

Gairdner, Public Health.

195

ton, will be found a series of facts showing that a want of ventilation of houses,
workshops, and unquestionably, in many instances, of schools also, may be fairly
set down as contributing towards the production of a large amount of the mor-
tality incident to pulmonary phthisis and the other forms of tubercular disease.
In 1824, Dr. Alison, in a paper published in the first volume of the Edinburgh
Medico- Chirurg. Transactions, endeavoured to prove that confinement, and
want of exercise, rather than cold or deficient nourishment, are the causes of
tubercular disease. The dependence of the latter upon vitiated air was also
maintained by Baudelocque in his treatise on scrofula, published in 1834; and
the same has been recently urged by Dr. M'Cormac, of Belfast, Ireland. Mr.
Toynbee has observed that, among the working classes of London, while scrofu-
lous and tubercular diseases are the result of ill-ventilated dwellings and work-
shops, in connection with destitution and an imperfect supply of food, gouty and
rheumatic disorders prevail among those who are driven by the physical ex-
haustion caused by working in an impure air to the use of alcoholic stimulants.

In his evidence before the Health of Towns Commission, Dr. Guy stated that
he had investigated with great care the circumstances attending the derange-
ment of health in 320 of the journeymen printers of London. After careful
inquiry he was enabled to arrange them in three classes nearly equal in numbers.
In the first class, the men habitually respired in their workshops an atmosphere
of less than 500 cubic feet of air per man ; in the second class, the quantity was
between 500 and 600 cubic feet ; in the third class, it was over 600 cubic feet.
Taking as his guides, two of the leading symptoms of consumption, which could
be easily detected by questions, he found that the difference between the first
and last of the above classes was as follows : Of the first, or luorst off" class, as
respects air, 12|- per cent, had spat up blood, and a like proportion had been,
subject to catarrh ; while, of the third or test off" class, only 4 per cent, had
suffered from spitting of blood, and only 2 per cent, from catarrh. The medium
class of workmen occupied also a similar medium position with respect to both
these unfavourable symptoms. In connection with the foregoing facts, Dr. G.
remarks : As the diff'erences are considerable between the comparative fre-
quency of scrofulous diseases, and of internal tubercular affections in diff'erent
localities, there must in all probability be some unknown specific cause of each^
to the activity of which a defective air supply is an essential, or nearly essential
condition. In connection with this obscure subject, it should not be overlooked,
that the contagious or infectious character of consumption has at different times
been a popular belief, and has also found favour with many good medical authori-
ties, although more usually set aside as deficient in evidence. Without wishing
to dogmatize on the subject, I think it must be conceded that the frequent occur
rence of the disease in connection with bad ventilation, is rather in favour of the
view of some degree of contagious property, and ought to inspire reasonable
caution as regards the too close approximation of the sick to the healthy. A
pure air by day and by night, is the only safeguard against this danger, if it
really exist, and considering the lamentably frequent instances of the wide diffu-
sion of the disease in families — though this does not necessarily presuppose
contagion — no precaution should be neglected that is consistent with the humane
and attentive nursing of the sick."

The volume before us comprises seven lectures. The first, or introductory,
refers to the care of the public health as a medical function. The attention
paid to it in early times ; the minute sanitary requirements of the Jewish cere-
monial law — a law which may in very many and important particulars be made
even at the present day our exemplar and our guide. The Roman sanitary
legislation is also cursorily noticed. The neglect of almost everything relating
to hygiene in the middle ages is commented on, and its consequences pointed
out, by a reference to the widespread contagious and other epidemics, which so
repeatedly desolated, at intervals, during this period, most of the large cities —
cities which appear to have been built and governed with the express intent of
excluding as much as possible the circulation of the air, the entrance of the
sun's rays, of crowding in as small a space as possible the inhabitants, and of
surrounding them with all manner of uncleanliness. The lecturer presents then
a rapid but most instructive sketch of the gradual and partial reform which was

196

Bibliographical Notices.

[July

at length brought about through the more careful study of certain epidemic
diseases by a few zealous i^hysicians, and the reyelations made by Howard and
others in respect to the condition of the jails, hospitals, and lazar-houses of
England ; until, in the present century and within the last thirty years, the
public mind being strongly and universally directed to the origin and suppres-
sion of pestilential diseases, through the labours of Mr. Chadwick and his col-
leagues, a series of investigations were instituted and eflfectually carried out to
determine from actual observation the sanitary condition of the labouring popu-
lation, and of the principal cities of Great Britain. From the results of these
movements, taken in connection with the body of vital statistics, contained in
the reports of the English Registrar-General. Dr. Farr, have been developed the
leading data upon which alone must be based a successful system of sauitery
organization, public as well as private, having for its object the security and
augmentation of the health of all classes of society, in every community, and the
prevention of pestilential diseases in their midst.

The second lecture takes up the subject of public health, in connection with
air and water as sanitary agents. In this portion of the course we are pre-
sented with some general views in relation to the causes of the deterioration
from the requisite purity of these two essential elements of health, and the
natural processes by which that purity is restored and maintained.

The impurity of the air and water in particular houses, cities, and other locali-
ties, is no doubt chiefly due to overcrowding, and to defective ventilation and
drainage. In consequence of such neglect, the impurities given off by the human
body in the course of its regular physiological functions, or generated during the
various processes instituted by man for his personal and domestic comfort, and
in the course of various industrial pursuits, by the neglect of cleanliness, also,
and the consequent retention of organic remains in a state of decomposition
about his person or premises, must necessarily be allowed to accumulate within
a comparatively small compass. With perfect ventilation and adequate drain-
age, these impurities would have been speedily dispersed and made to undergo
by means of the subtle chemistry of nature such changes as were required to
render them supporters, instead of disturbers or destroyers of vitality.

To secure adequate ventilation and drainage would appear, therefore, to be
among the primary means to be instituted for the maintenance of health in the
individual and the warding off of pestilential disease from communities. Such
is certainly the case, whenever by ventilation we introduce a constant current
of pure air in and around our dwellings. For we are to recollect that the very
air which is caused to flow into our dwellings, our workshops, our school rooms,
our churches and other places of public resort, may be itself the means of com-
municating disease, from the impurities it has imbibed in its passage over places
in our vicinity where there exist sources of morbific emanations. A city, or
village or tract of country may be rendered eminently unhealthy if it be so
situated that the prevailing winds traverse an extensive malarious district, or
one abounding in marshes or large collections of stagnant water. So, also,
drainage and the removal of every species of obstruction in our streams and
water-courses generally, however fully accomplished, though always productive
of beneficial effects in a sanitary point of view, will not alone always supply us
3?rith pure potable water. The sources of the water may be such as to cause it
to be impregnated with saline or other ingredients, or these may be poured into
it along its course in such quantities as to render it unfit for use as a drink.

The subject of impure air and overcrowding is very well treated of in the third
lecture. Its influence as a sanitary agent is amply illustrated by frequent refer-
ence to the facts developed in the reports of the Health of Towns Commission,
ec«pecially those in regard to Liverpool.

In the conclusion of this lecture Dr. G. makes the following highly important
remarks : —

" The great evil that we have to fix upon, as a guide to the purification of the
air, is. the fact of epidemic disease in connection with overcrowding. But,
although that is the form we must chiefly fix upon, I am not at all sure that
epidemic disease is the form of evil that does the most damage to the public
health. A vast amount of mischief is caused, no doubt, by the spread of such

1862.]

Gairdner, Public Health.

197

a disease as typhus fever, which too often cuts off the head of a family. A
somewhat less, but still a considerable amount of evil is produced by the diseases
of measles and scarlet fever, which often destroy the children of a family, and in
many cases, where the children are not destroyed, leave them with a weakened
vitality, which lessens their value and usefulness as members of society all the
rest of their lives. But, I am not sure that even a greater amount of physical
deterioration is not produced by the tendency of overcrowded apartments, and
a deficiency of free ventilation, to sow the seeds of tubercular disease, and par-
ticularly of pulmonary diseases of all kinds, Knowing, as we do, that from a
seventh to an eighth over all England, and probably from a sixth to a fifth, or
even a fourth, of the population that die in some of the great towns, fall victims
to some form or other of tubercular disease — whether this does not present even
a more terrible picture than the other, of the cousequences of deficient ventila-
tion. In the case of consumption, alone, we are dealing with a disease which
annually destroys more than 50,000 persons in England and Wales, and we are
very sure that a large proportion of this immense mortality is an avoidable
mortality, inasmuch as we know to what an extent it occurs in close and un-
wholesome houses, workshops, schools, and places of public resort. If the
prevalence of this one disease could be reduced, say by one-half, or even one-
third, through systematic attention to the principles of public health, it would
be far more than worth, in mere money value, a sum equal to the interest of the
national debt."

The subject of the next two lectures — the fourth and fifth — is water in refer-
ence to public health. The necessity of an adequate supply of water for culi-
nary purposes, for the maintenance of personal and domestic cleanliness, and as
a beverage, is pointed out, and the importance of the supply being of water of
the purest quality that can be obtained, especially in reference to its use in the
preparation of our food, and still more so as our common drink, is strongly
enforced by Dr. G.

In the fourth lecture, which treats of the water supply and the injury which
must necessarily result when this is deficient, there are announced many general
truths which are applicable alike to every community, nevertheless, most of the
facts, arguments, and illustrations of the lecturer, under this head, have more
especial reference to the water supply of Edinburgh and London. They are but
partially applicable to the leading cities of the United States, in nearly, if not
all of which an ample supply of water is furnished, and at so small an annual
expense, that even the poorest individual or family may avail himself of it,
without stint, for every purpose for which it is required.

The subject of impure water is discussed in lecture five. The causes by which
water may be rendered impure, and thus unfit for the use of man, are numerous.
The great majority of them it is within our power entirely to remove. It is
chiefly those causes through which the water becomes loaded with organic
remains in a state of decomposition that render it the most prejudicial to health.
Hence the well-founded prejudice against the use of the water of marshes, shal-
low ponds, and, indeed, against the use of water that, in any situation, has re-
mained for a long time stagnant. Hence the unwholesomeness — an unwhole-
someness frequently but little suspected — of water that has passed through a
soil which has become strongly impregnated with decomposing animal remains,
and exuvijE ; a soil too often to be met with in the midst of large cities with
their numerous ill-constructed sewers, cesspools, and graveyards.

The principal circumstances under which water becomes dangerously impure,
are enumerated by Dr. G. as follows : First. When a neighbourhood, situated
at a lower level than the other portions of the city, town, or village, to which it
appertains, receives the entire drainage of the higher grounds. Second. When
the drainage is defective, or the drains and common sewers are so constructed
as to leak into the subsoil, or to become choked, so as to cause their frequent
overflow. Third. When the drainage is into a river or stream from whence,
and within the poisonous influence of the sewage, comes the water supply of the
people. Fourth. When there is no proper or adequate system of drainage,
impurities being allowed to accumulate upon the surface and soak into the soil,
while the leakage from cesspools is widely diffused throughout the subsoil so as

198

Bibliographical IS'otices.

[July

to contaminate the watei' courses and wells from which the water supply is
obtained.

The lecturer adduces many striking facts, proving most clearly the influence
of impure water in the production of endemic and epidemic diseases — of cholera,
dysentery, and various other maladies of a very serious and deadly character.
He strongly enforces the view which refers the dissemination of cholera chiefly
to the use of water impregnated with a particular poisonous matter. With the
view of establishing the correctness of this view, he attempts to show by facts,
the accuracy of which cannot be disputed, that cholera is a disease of low levels,
but not of all low places and low levels even within the geographical limits in-
vaded epidemically by the disease, thus showing that other and opposite tenden-
cies are sometimes at work in particular localities. In respect to cholera, he
remarks : —

" We want a cause of disease which is consistent with its communication from
man to man, and along the great lines of human intercourse, yet which does not
imply a large amount of contagious or infectious power, in the ordinary sense of
a disease which is ' catching,' through the breath or exhalations of the skin ; a
contagion, in short, which allows of your approaching the sick, or remaining in
the same room with them, with little danger as compared with the case of fever
or of smallpox. All these conditions are met by the theory of a poison commu-
nicated from the sick to the healthy, but communicated chiefly through water,
and only to a comparatively slight extent through the air. This, accordingly,
is the modern theory of the diffusion of cholera. We have come to believe that
it is, indeed, as the Hindoo supposes, a disease dependent upon poisoned water,
only the poison is not an extraneous one, but is generated and reproduced in and
by the bodies of the sick."

The subject of drainage and sewerage are treated of in a very general man-
ner in the sixth lecture. In the seventh is discussed at some length the subject
of sanitary organization. That is an organization having for its sole object the
promotion of the public health of the community generally, by devising and
procuring such legal enactments for the security of the public health as may be
found necessary and proper; by co-operating with the State and municipal ofiBcers
in the enforcement of the measures which these enactments provide for; by
securing to every neighbourhood, family, and individual, in the community, a
constant and adequate supply of pure air and pure water ; by communicating,
as far as is possible, to every class of the people, advice and instruction in regard
to such a mode of living, within their means, as shall the most certainly conduce
to their health and well-being ; and to place within the reach of all the means
for regular bathing, proper, economical, and wholesome cookery, and the accom-
modations furnished by improved boarding, and tenement houses.

The leading facts and arguments employed by Pr. G. in the illustration and
enforcement of the principles laid down by him in these concluding lectures, are
derived almost exclusively from the condition of the people in the different cities,
towns, and villages of Great Britain. While his reformatory measures, and the
manner in which he proposes to secure their accomplishment, have reference
mainly to the poor and labouring classes of that kingdom, they will, nevertheless,
be found, to a very great extent, applicable also to the condition of things
which prevails amid the several communities of the United States. The discus-
sion of the subjects referred to by Dr. G. presents much that is highly instructive.
His fifth and sixth lectures, equally with those which precede, deserve a careful
study on the part of every one interested in the etiology of disease, and who
would desire to promote the inauguration and enforcement of measures adapted
to remove the causes of endemic maladies. Although these measures cannot
effect as much in respect to those maladies which prevail epidemically, they
will be found, at least, to disarm them of their malignancy, and circumscribe to
a great extent their prevalence.

subjects of deep interest to the sanitary reformer, and a familiarity with which
is calculated to promote the cause of public health.

We may here remark that the volume before us does not contain all the lec-
tures which composed the course as actually delivered by Dr. G. Five lectures

appended in reference to

1862.]

Gairdner, Public Health.

199

are omitted from the fact of their being exclusively devoted to the mere technical
and scientific consideration of the various circumstances bearing on the death-
rate, and on the application of the Registrar-CSreneral's data to sanitary purposes.

Notwithstanding the length to which we have already extended our notice of
the lectures of Dr. Grardner, we cannot refrain from laying before our readers
an extract or two from the recapitulation with which the sixth lecture concludes.
They speak most solemn truths in respect to the important subject of public
hygiene, which cannot be too often urged upon the attention not merely of
physicians, but of our State and municipal legislators, and of the citizens
generally.

"• I cannot close this lecture, and with it the review of the consequences of our
neglect of the first elements of public health, without pointing out to you, once
more, how many of the other evils that affect the lower classes of our population
are connected more or less directly with the want of a sufficiency of pure air and
water in the home. ^ ^ * Pure air and water, then, are necessary to much more
than health and mere physical comfort ; they involve in themselves inextricably
the first elements of almost all the social virtues, because, where you cannot
have cleanliness, you cannot long have either self-respect or respect for others,
without which none of the social and practical virtues can get soil, so to speak,
to take root. And, accordingly, it is the inevitable consequence of leaving a
large population in a permanently impure and unclean state, that habits are
created destructive of the social virtues ; and in the course of a few generations
the very germs of these virtues, the germs of morality and decency, of all the
little charities and graces of social life, and, finally, of all the attributes that
lift man above the brutes, die out in the infected atmosphere of physical de-
gradation."

The picture which Dr. G. here paints is, as he remarks, a hideous one ; it will,
nevertheless, be found to delineate, with but very little exaggeration in any one
of its features, the actual condition of the lowest classes in some of our great
cities. Nor can it be considered a mere hypothetical supposition to refer the
origin of all the revolting features depicted to the degrading influence conse-
quent upon a deprivation of the two principles of health— public as well as
private — air and water, pure in quality and ample in quantity. Proof conclu
sive in support of the correctness of the views so ably set forth by the lecturer
can be furnished from the annals of the degraded classes of our own cities, but
more especially of the cities of Europe, where the supply of air and water is
cut off from the poor to a much greater extent than it is with us, as well by
their own improvidence as by the desire for gain irrespective of everything else,
on the part of a certain, and, unfortunately, too numerous class of property
holders. In a later part of his recapitulation, Dr G. uses the following impres-
sive language : —

"Observe, then, the complicated effects of physical impurity, or even the
neglect of comfort in the home. Besides the bad efiects upon the health directly,
it creates a lowered tone of feeling and of personal delicacy: in the worst cases,
it almost obliterates the sense of shame, and leads to an indiscriminate and
shockingly depraved commerce of the sexes. When the evil falls short of this,
it makes the home untidy and wretched, at first, in spite even of the struggle
after better things. Then the character of the household deteriorates ; the
woman gradually loses her feeling of satisfaction in her home ; she feels that it
is impossible for her to make it, what she ought, an attraction and a pleasure to
her husband. Then quarrels occur, and the liome becomes unbearable at times ;
finally, the evil extends to the husband, in a far more pernicious shape still,
making him permanently careless and negligent, unfond of his home, unfond of
his wife and of his children, and in too many instances fond of some deleterious
substitute for the enjoyments of home and the tranquillizing influences of a
virtuous family life. It is here, beyond all doubt, I believe, that we must look for
the source of much of the drunkenness and other vices of the labouring classes."

This relationship between public and domestic hygiene — with the real com-
forts which follow its due enforcement — with the improved moral deportment and
happiness of the labouring classes, has, heretofore, been too much overlooked.
It is well founded, nevertheless, and furnishes an additional and very weighty

200

Bibliographical Notices.

[July

argument in favour of a careful study of everything having for its object the pro-
motion to the greatest and widest extent of the public health.

''Need it be said," inquires Dr. G,, "that the terrible evils of a disturbed
family relation, and a disordered home, tell with fearful force upon the health,
the morals, the habits, and the lives of the rising generation, and especially of
the very young children? It would be marvellous, indeed, if it were not so.
I should not know what to believe. If I found that a disorderly home did not
tell upon those exquisitely tender, delicate lives, which, as I showed in a
former lecture, are three or four, or five or six, in some cases even ten times,
more subject to destruction than are the lives of members of the community at
other ages. But we are not left to speculate on this matter. We know, as a
fact, that the lives of young infants are not only very fragile, but are actually
sacrificed to an enormous extent wherever the home is neglected. In a former
part of this course, I showed that the variation in the death-rate of very young
infants is not less than enormous, as compared with that of adults ; so that
while the difference between the healthiest and the most unhealthy district of
England, as respects the death-rate of the whole population, is not more than
about 15 in 1,000 living, the diff"erence in respect to children under five years is
nearly 90 in 1,000, and the difference as to children under one year is, I have
reason to believe, more than 200 in 1.000 liviug. There are, indeed, not a few
places in which, counting over large numbers of the population, the children
are thus mismanaged: Where the domestic relations of the populatiou. taken
as a whole, are so bad that not less than a third, probably indeed much more
in some places, of all the children born fall victims to disease, or are in some
way or other destroyed before they are even one year old — before their little
limbs have learned to walk, or their tongues to speak, and while they yet are, or
ought to be, drawing their food from the breasts of their too careless, or perhaps
yet more unhappy mothers. I hardly know a fact in the long story of human
guilt and misery more deeply impressive than this." * * *

Many more extracts might be made, showing how intimately health and pros-
perity, and civilization — all things, indeed, which concern the happiness of indi-
viduals and communities — are connected ; that it is not less the duty than the
interest of the community to see that the means of personal and domestic clean-
liness, the free use of the commonest and most indispensable of God's gifts, air
and water, are brought within the reach of all, and that they are, as far as prac-
ticable, properly applied. But we refrain; we at the same time recommend the
volume of Dr. G. to the careful study of every one. The author has presented
in a plain and forcible manner the important subjects of which he treats, and
has adduced a large amount of facts in illustration of their true character and
of the correctness and cogency of the arguments by which he has endeavoured
to enlist in their behalf the public mind and organized co-operation. It is in
the proper sense of the term a popular book for popular use. D. F. 0.

Art. XXII. — Tlie Ambulance Surgeon, or Practical Observations on Gunshot
Wou7ids. By P. L. Appia, M. D., Fellow of the Koyal Society of ^•aples, &c.
Edited by T. W. Nuxx. Assistant Surgeon to the 'Middlesex Hospital, and
A. M. Edwards, F. R. S. E., Lecturer on Surgery in the Edinburgh Medical
School. Edinburgh, 1862. 12mo. pp. 266.

This volume contains the translation, somewhat condensed, of a French work
on gunshot wounds, written by Dr. Appia, together with some additions made
by the British editors.

Dr. Appia's work is evidently the production of an accomplished surgeon, of
one who has studied the literature of his profession, and who has himself, had
experience both in hospitals and on the field. It is divided into two parts, the
first treating in separate chapters of the nature and varieties, the diagnosis, the
prognosis and complications, and the treatment of gunshot wounds, and the
second part considers gunshot wounds in the different parts of the body. The

1862.]

Mitchell, Circulation in the Snapping Turtle.

201

general outline of the treatise is, therefore, the same as that in the favourite
work of Professor Longmore, to which, though as a whole it must be considered
as inferior, this will be found decidedly superior on the subjects of prognosis
and of complications. Of course the tone of the work is altogether different,
and, from being less dogmatic, it is more agreeable.

The chapter on the first dressing of fractures of the limhs contains, among
much other excellent matter, the description of an apparatus for fractures,
which appears to enable the wounded man to be transported with remarkable
facility under the most disadvantageous circumstances. As it is stated thaf,
after having been tried in the army of Italy, this apparatus was introduced into
the military hospitals of Paris and Turin, and into the Spanish army, it is
evidently worthy of being made known in this country.

The great peculiarity of this apparatus consists in a number of small splints
and vulcanized India-rubber air-cushions, that can be inflated at pleasure, all
bound in strong canvass, so that the limb can be entirely surrounded. The
apparatus varies in the size and number of the cushions ; in the simplest, in-
tended especially for wounds of the knee, the leg, and the foot, there are four
cushions, about twenty inches in length and six in breadth, with five narrow
splints, with three straps to buckle the apparatus around the limb. For frac-
tures of the thigh and for complicated wounds of the knee, there is along splint,
of very ingenious construction, composed of several pieces, intended to admit
of its extension, and yet form as firm support as if they were all one piece of
wood. The comprehension of the description of this apparatus is aided in the
text by a number of figures. Dr. Appia says experience has proved that by
this apparatus the leg is entirely secured from any shocks from without. " One
may even sit down upon it violently, when fixed and buckled up, without the leg
experiencing anything beyond a slight increase of pressure. All shocks from
without spread immediately, by the law of undulations, through all the cushions,
and produce only a trifling direct effect."

There is little to be said that is favourable of the manner in which the British
editors have performed their task in this volume,, whether as translators or as
original contributors. As an example of the one the following extract will be
sufficient, and the mistake as to the signification of la rage will be found
amusing: —

" All that reminds us of similar conditions produced by hydrophobia. I have
observed a young girl who sunk in a few days after a fright which placed her in
a condition between tetanus and passion (rage). She swallowed with difficulty,
and only when the drink was brought to her from behind, and in almost total
darkness ; my arrival, or the sight of any one approaching her, set up tetanic
spasms. The post-mortem offered no explanation. To these negative precau-
tions will be added the employment of direct calmatives, especially full doses of
opium; Larrey advises its being associated with camphor." (pp. 99-100.)

The original contributions of the editors, which consist of a short article on
Disinfectants, and a part — sixty pages in length — on Surgical Appliances, have
been added, it is to be hoped, without much reflection. W. F. A.

Art. XXIII. — Experiments and Observations uponthe Circulation in the Snap-
ping Turtle, Chelonura Serpentina, toith especial Reference to the Pressure
of the Blood in the Arteries and Veins. By S. Wier Mitchell, M. D., Lec-
turer on Physiology. Philadelphia, 1862. 4to. pp. 14.

In this interesting memoir are detailed the results of a series of experiments
instituted with the view of determining in the snapping turtle the force of
the heart's coatraction, the degree of the arterial and venous blood-pressures,
and the influence exerted upon these by inspiration, expiration, and muscular
exertion.

The instrument used in these experiments was the haemometer of Magendie,
as modified by Bernard, and described by him in his well-known lectures on
the "Liquids of the Organisms."

202

Bibliographical Notices.

[July

From observations made upon the pressure of the blood in the carotid arteries
of eight snapping turtles, Dr. Mitchell found that the minimum pressure in the
artery is about one-third that in the artery of a mammal, or as 33.3 to 110, 103
or 95, according to the animal chosen for comparison.

" The force of the heart-act in the turtle elevates the column, on an average,
11 m. ra., which is about the pressure observed in a dog of middle size when
tranquil, and when the respirations do not prevent accurate observation of the
influence of single pulsations, as is commonly the case.

• " The impulse conveyed to the column of blood during the systole of the heart
in the turtle is somewhat different from that of the mammal. In place of a
sudden and abrupt motion, as seen in these latter animals, the mercury moves
so slowly that the time of its rise during a systole may be estimated at one
second, the period of fall being one second and one-fifth. The rise of the mer-
cury was usually steady and regular ; its fall was broken and irregular, so that
after falling two-thirds of the distance rapidly, an equal time was occupied in
effecting the remaining third of the total descent. The number of heart-pulsa-
tions varied in the eight animals examined from 25 to 40. In the individual
cases its number was scarcely altered during the whole observation."

The full and slow expiration which forms the first act of the respiratory pro-
cess in the turtle exerts no marked effect upon the arterial pressure. The long
inspiration which follows usually increases this pressure a little. The short
expiration which terminates the respiratory series at once varies the arterial
pressure.

" The effect of muscular movement upon the pressure of the blood in the
arteries was well marked and interesting. During violent movement the force
of the heart remained unaltered, but the whole column of mercury rose, a result
which attained to a maximum when the movements were coincident with the
long inspiration and the short expiration which terminate each single series of
respiratory movements. On such occasions the mercury sometimes rose as high
as 70 m. m., and the action of the heart was irregular and unequal in force.
Immediately after the movements were over, the mercurial column fell to a
much lower point than usual, and then gradually ascended to the normal
standard."

We regard this monograph as an inte^:'esting addition to the literature of ex-
perimental physiology, and we hope that the author will complete the study so
well begun, by future more elaborate investigations. J. A. M.

Art. XXI Y. — A Manual of Medical Diagnosis ; being an Analysis of the Signs
and Symptoms of Disease. By A. W. Barclay, M. D., F. R. C. P., Assistant
Physician to St. George's Hospital, &c. &c. Second American, from the
second and revised London edition. Philadelphia : Blanchard & Lea, 1862.
8vo. pp. 451.

Having fully reviewed this work when it first appeared, a short time since, it
is sufficient now to say that the rapidity with which the first edition has been
exhausted shows the appreciation in which it is held by the profession.

The very early period, the author states, at which a call has been made for a
second edition of this manual has prevented his attempting anything in its revision
beyond verbal alterations and minor additions. And he very modestly adds :

While I take this opportunity of expressing my gratitude for the hearty good
will with which my effort to supply an acknowledged deficiency has been received,
and for the kindly tone of all the criticisms which have reached me, I cannot
but feel that it owes its success more to the earnestness of purpose which cha-
racterizes the students of the present day than to any merit of its own."

We commend the work to the medical student as affording useful aid in ob-
taining knowledge in a department of our science, the acquisition of which is
essential, that our science may rest on a sure and solid foundation.

1862.]

203

QUARTERLY SUMMARY

OF THE

IMPROVEMENTS AND DISCOVERIES

IN THE

MEDICxiL SCIENCES.

ANATOMY AND PHYSIOLOGY.

1. On the Tactile Sensibility of the Hand. — Dr. Ballaed read before the
Royal Medical and Cliirurgical Society (March 11) a paper, the first of a series,
on the tactile sensibility of the surface of the body. The method he has em-
ployed for ascertaining the sensibility of the parts examined was that known
as Weber's ; but inasmuch as the results of this method vary according as the
points of the compasses are laid in the direction of the long axis of a part or
transversely to it, he employs the sum of the numbers obtained by an observa-
tion in each direction as representing the true sensibility of any part. The
numbers are given in English inches and decimals. He considers that the hand,
being par excellence the organ of touch, and possessing on the whole the highest
amount of sensibility, and giving thus readily a standard for comparison of sub-
jective impressions made elsewhere, it is important that it should be the organ
first examined. The paper is based upon the results of observations made upon
142 points upon the surfaces and borders of the author's own hand and fingers
— in all, therefore, of 284 separate observations. It consists mainly of elaborate
tables, from which the author deduces in due order the general sensibility of the
hand and its surfaces and borders, and separately of the metacarpal portion,
fingers, and thumb. He not only compares these several parts between them-
selves, but points out the relative sensibility of the lateral halves of the hand,
these being related to the freer motion imparted to the radial half ; and of the
centre to the sides, as showing at what parts of the hand the sensibility is highest
at any given distance from the wrist. The following are some of the more im-
portant deductions : The most sensitive spot of all he finds to be the tip of the
index finger, in which he differs from Weber, but agrees with Yalentin. The
sensibility of this spot is represented by the number .35 in. The spot where he
found the lowest sensibility (.5.0 in.) was on the dorsum of the hand, opposite
the base of the fifth metacarpal bone. The palmar surface of the hand was in
all parts more sensitive than the dorsum ; but this was not the most sensitive
part, for next to the tips of the fingers stood in order the two borders, the radial
border being more sensitive than the ulnar. As pointed out by Weber, he also
found that the sensibility of the hand increases from the base towards the ex-
tremity ; but the author exhibits this fact by accurate numbers, and demonstrates
not only the increase but also the rate of increase on each surface and border
of the hand and of each finger separately. He finds the most rapid increase in
sensibility to take place at the spot where the fingers actually commence, not
where they apparently commence, and thus not at- the clefts, but opposite the
metacarpo-phalangeal articulations, and again at the middle of the last phalanges
on approaching the tips of the fingers. Perhaps the most interesting and im-

204 Progress of the Medical Sciences. [July

portant demonstration of all is that which relates to the fingers and their several
surfaces. On the whole, the most sensitive finger is the index, and the sensitive-
ness shades off towards the ulnar side of the hand ; and the most sensitive por-
tion of the index, next to the tip, he finds to be its radial side. Of the little
finger, the most sensitive part is the ulnar side, and he connects these two facts
with those parts entering into the constitution of the borders of the hand at large.
Of the palmar surfaces of the fingers, that of the index is the most sensitive ;
of the dorsal surfaces that of the ring finger is the least sensitive. As respects
the radial sides of the fingers, he finds the radial side of the index to be the
most sensitive, and that the sensibility shades off as the fingers are farther re-
moved from the radial side of the hand, till it becomes least upon the little
finger. As respects the ulnar sides, he finds that that of the little finger is the
most sensitive, and that the sensibility becomes less as the ulnar side of the hand
is distanced ; with this remarkable exception, however, that the high sensibility
of the index is provided for by its ulnar side standing next in rank to that of the
little finger. Of the three intervals between the fingers, that whose approxi-
mating surfaces possess the highest sensibility is the interval between the index
and middle fingers. The thumb is, for the sake of convenience and simplicity,
considered separately, and is regarded, from its carpal attachment onwards, as
a finger not having a metacarpal element. It is thus compared in the paper
with the fingers, from their metacarpo-phalangeal joints onwards. Appended
to the paper are tables exhibiting the observed sensibility in each direction at
the several spots examined, and four photographs on which are marked the sums
of the observations at each spot. The author reserves the consideration of the
differences of result according to the direction in which the compasses are placed
for a future communication. — Med. Times and Gaz., March 29, 1862.

2. Valves of the Veins of the Extremities. — M. Yerneutl made the following
observation, at the Paris Anatomical Society, on the venous system of the
extremities. While some of the arteries are accompanied by only a single vein,
others have two venous satellites. The former are the encephalic, pulmonary,
cardiac, uterine, and thyroid veins, and those of the portal system. These are
all destitute of valves, while the veins of the limbs, which are always double in
relation to the artery, are all possessed of valves. Is there here anything beyond
a mere coincidence, any relation of cause and effect? Is not the existence of a
double vein the consequence of the presence of the valves ! When we contem-
plate the amount of pressure exerted upon the valves by the column of blood,
we feel surprised that these folds are enabled to fulfil their office, and that their
resistance is not oftener overcome by the obstacle which they have to surmount.
But our surprise ceases when we consider that each of the segments of the vein,
of the portions comprised between two valves, is provided with what may be
termed a safety canal, that is, a vascular tube, which, arising a little above the
lower valve, is directed at first horizontally, then vertically, and then again hori-
zontally, so as to enter above the superior valve, presenting towards the superior
extremity of its vertical portion a valve so disposed that the blood may in this
safety canal flow towards the heart, but not in the contrary direction. Each
segment of the vein is provided with a similar canal ; and supposing these canals
conjoined, they would constitute a single safety-tube, the vertical portions of
which represent the second vein attached like the first to the artery, while the
horizontal portions represent a transverse anastomoses which establish a con-
stant communication between the two parallel veins. This safety-tube is pro-
vided with valves disposed as noted, and which only allow of a concentric move-
ment of the liquid. The second vein thus serves as a derivative for the first,
which in its turn plays a similar part for the second. From this reciprocity of
action there necessarily results a well nigh complete equality of volume for the
two vessels. " This explanation applies to all the veins of the extremities, and,
in a general manner, to all veins having valves. The femoral vein, which at
first sight seems to offer an exception to the rule, nevertheless presents the same
disposition, for an attentive examination will demonstrate that there exists by
its side a second vessel of smaller dimensions, communicating with the first by
numerous anastomoses, each of which always opens into the principal vessel

1862.]

Anatomy and Physiology.

205

above a valve. — Med. Times and Gaz., May 10, 1862, from Balletin de la Soc.
Anat., vol. xxxvi.

3. Marriages of Consa,nguinify and Deaf -Dumbness. — M. Boudin, so well
;]?nown for his researches in medical statistical questions, thus concludes an
interesting inquiry concerning the effects of marriages of consanguinity : 1.
The opinions hitherto delivered, whether for or against the hurtfulness of these
marriages, have, for the most part, not been based upon conclusive proofs. 2. It
is the statistical method that can alone supply a scientific solution of the pro-
blem. 3. It results from my own researches that consanguineous marriages are
contracted in France at the rate of 2 per cent. ; and that deaf-mutes are the
issue of consanguineous marriages in the proportion of 28 per cent, at the Paris
Imperial Institution, 2.5 per cent, at Lyons, and 30 per cent, at Bordeaux. 4.
Marriages between nephews and aunts are contracted in France in the propor-
tion of 0.014 per cent, (fourteen thousandths per cent.), while deaf-mutes are
the results of such marriages in the proportion of 2.04 per cent. — in other words,
deaf-mutes resulting from such marriages are 145 times more numerous than
they should be. 5. Marriages between uncles and nieces are contracted in the
proportion of 0.04 per cent, (four hundredths), and the deaf-mutes resulting from
such marriages reach 1.61 per cent., i. e., the danger of engendering deaf-mutes
is 40 times greater in this kind of alliance than it is in ordinary unions. 6. Mar-
riages between cousins german are contracted in the proportion of 0.77 per
cent., and deaf-mutes are produced in the proportion of 18.47 per cent., i. e.
24 times more frequent than they should be. 7. The proportion of deaf-mutes
proceeding from a consanguineous origin would be still greater if we could take
into account those which proceed indirectly from consanguineous marriages.
8, While at Berlin the proportion of deaf-mutes is but 6 in 10,000 among the
Christians, it is 27 in 10,000 among the Jews. 9. In nearly the whole of the
cases, the deaf-mutes issuing from consanguineous marriages have parents who
are perfectly healthy and exempt from hereditary affections. 10. When male
and female deaf-mutes intermarry, not being consanguineous, the children they
produce, with rare exceptions, are exempt from dumbness and deafness. 11. In
the face of such facts as these, the hypothesis of a morbid hereditariness, em-
ployed for the explanation of the frequency of deaf-dumbness among infants
the results of consanguineous marriages, is radically false. 12. The hypothesis
of the pretended harmlessness of consanguineous marriages is contradicted by
the most evident and well-verified facts, and can only be excused by the diffi-
culty, or rather the impossibility, of giving a physiological explanation of the
production of infirm children by parents who are physically irreproachable.
M. Boudin, in proof of the practical importance of this kind of inquiries, states
that since 1831 more than 15,000 men have been exempted in France from mili-
tary service on account of deaf-dumbness, dumbness, or deafness. — 3fed. Times
and Gaz., May 10, 1862, from Receuil de M^m. de Med. Militaire, March.

4. Marriages of Consanguinity and their Influence on Offspring. — A very
interesting and elaborate paper on this subject has been lately read (February
6, 1862) before the Medico-Chirurgical Society of Edinburgh, by Dr. Mitchell,
of which the following is an abstract : —

Dr. Mitchell began by a brief account of existing opinions on this subject. He
pointed out that whatever the practice may be, such alliances are, and have
always been, almost universally condemned both by the general public and the
medical profession. And as every one has considerable opportunities of testing
its accuracy by personal observation, he argued that the probability of its being
a traditional error becomes very small. He stated that the literature of this
subject abounded in simple assertion, which might be correct, but that the basis
on which important conclusions are made to rest is often not given at all, and
when given, is undefined or clearly too narrow. He pointed out that much of
the general and professional opinion on this subject hangs on a peculiar kind of
evidence. A¥e are presented with the question, "Do these marriages injure the
offspring?" and we search for instances from the history of which the answer is
to be given. Now it is certain that all those cases which have been marked by

206

Progress of the Medical Sciences.

[July

misfortune will first rise up, while many of those which have exhibited no evil
effect or no peculiarity will probably be passed over because forgotten. Facts
so collected lead to inferences beyond the truth — an exaggeration of a calamity
whose proper dimensions are sufficiently great. Without intention they are
selected cases. Being true in themselves, they show what is possible, but they
by no means embody the rule. He then detailed the results of 45 cases so col-
lected by himself. Some of these he discussed individually as illustrative of
atavism, of the connection between heredity and his subject, of the various forms
of injury and modes of manifestation, etc. The line of investigation to which
these considerations had led was then described. Instead of grouping cases,
supplied by his own memory or the memory of others, he took small communi-
ties, examined the history of every such alliance in these communities, as well
as of every marriage without kinship, and compared these. And in order further
to test the result of such inquiries, he ascertained, with as much accuracy and
precision as possible, the history of the parentage of all insane or idiotic persons
in a particular district of the country. These inquiries were conducted by himself,
bis official duties giving him the necessary opportunities. In addition to show-
ing the influence of consanguinity of parentage on the production of the actual
idiocy of the country, he also showed its power as a cause of actual deaf-mutism.
And he examined at some length the argument from in-and-in breeding in the
lower animals. By this mode of investigation he hoped to obtain sounder con-
clusions as to the character and measure of the pernicious influence which blood
alliances exercise on the offspring.

Taking the whole number of idiots examined (711), out of every eight one was
the fruit of a union of consanguinity. This includes those cases where the rela-
tionship of the parents could not be ascertained, as well as illegitimates. When
these were excluded, and when those idiots horn in marriage of parents related
by blood were compared with those horn in marriage of parents not so related,
they stood in the proportion of 1 to 5.8 — or more than every sixth idiot born in
wedlock was found to be the child of cousins. It further appeared that the
influence of kinship of parentage as a cause of idiocy manifested itself still more
strongly when those cases only were dealt with in which more than one idiot had
occurred in a family.

As regards the deaf-mute the influence was not so marked, but was still very
evident. In Great Britain one deaf-mute in 16.7 was found to be the child of
cousins. This closely agrees with Mr. Wilde's estimate for Ireland, but is not
so high as that formed by Dr. Peat and Mr. Buxton.

These subjects, which were discussed at considerable length, are here stated
in the briefest manner possible ; but when the paper is published the whole
details will be laid before the profession.

Dr. Mitchell, in examining the argument from in-and-in breeding in the lower
animals, discussed the views on this subject expressed by well-known writers and
stock-breeders, and concluded with the following remarks : —

" Everything is secondary to the property of producing in the shortest time
the largest quantity of flesh with the least consumption of food. The great
desideratum is an early arrival at maturity, or premature age — an early maturity,
too, of particular parts, of muscle and fat especially.

After all, then, in these cases where in-and-in breeding has been practised
with so-called good results, the issue is nothing but the development of a sale-
able defect, which, from the animal's point of view, must be regarded as wholly
unnatural and artificial, and not calculated to promote its well-being, enjoy-
ment, or natural usefulness. And in this view all the seeming contradictions
to the law disappear. By in-and-in breeding we may establish an artificial type,
and fix a peculiarity which is unnatural, if not morbid, and whose only value is
its profitable convertibility into gold, but no evidence whatever exists in these
apparent anomalies that by such a system of breeding we can improve the natural
animal.

"Strictly viewed, Collin's ' Comef was nothing more or less than a perfect
pathological specimen — a deviation from a natural animal — perfect in a desired
direction. Yet, pro tanto, the animal was the less useful to himself, had he been

1862.]

Anatomy and Physiology.

207

left to himself, and had he been deprived of the artificial keeping and manage-
ment which his artificial condition demanded.

" When it became desirable to perpetuate a peculiar malformation in man,
then in-and-in breeding may have good results — the results being estimated as
good or bad according as they realize the end in view. I know the case of a
man who has supernumerary little fingers, and whose two children and seven
grandchildren have the same. Were additional little fingers of great value, the
true way to obtain a race having this peculiarity, would certainly be to establish
blood alliances in this family ; and when we obtained the desired excess of fin-
gers in the offspring, we should then have as good reason to say that kinship of
parentage had done good and not harm (since we should have in the way we
wanted a more perfect animal); — as the farmer has to say, it has done no harm
but good, when he looks on his Leicester sheep, with little heads and small bones
— their lymphatic temperaments enabling them to feed without disturbance —
fat, ripe, and ready for sale in their very lambhood.

"Till the excellences of man are estimated by weight; till the man be an arti-
ficial, and not a natural man ; till we want legs at the expense of arms, or arms
at the expense of legs, or head at the expense of body, or body at the expense
of head ; till we want maturity in babyhood and premature age ; till the perfect
man be something else than a well-balanced development of all his components,
bodily and mental, we must apply the experience of breeders of artificial stock
cautiously and with reservation in human physiology."

That part of the communication which related to the examination of particular
communities embraced several fishing villages on the N. E. and S. E. coast of
Scotland, as well as iSt. Kilda, Bernera, and other islands off" the N. W. coast.
The account of this investigation was full and minute, and the aspects of the
question thus brought under notice were very varied. The nature of some of
these will be gathered from the conclusions to which Dr. Mitchell has been led,
and which are stated below. Many apparent exceptions were pointed out, and
attention was directed to those things by which the effects are influenced or
modified. The general teaching of the whole, however, decidedly pointed to
injury to the offspring as the result of a blood-relationship jDetween the parents.
It is not possible to give here even an abstract of this portion of Dr. Mitchell's
paper. Each place selected for investigation differed widely from the others,
and by peculiarities so decidedly aftecting the results, that nothing short of a
full detail would be satisfactory. The extraordinary influence of trismus on the
infant population of St. Kilda, for instance, appeared to destroy the lesson which
it was expected to teach. One pleasing conclusion to which these investigations,
led was, that such marriages are not so frequent in Scotland as has been long
supposed ; and it was stated that the enlightened proprietor of the Lewis does
all he can to prevent their occurrence among his tenantry.

Dr. Mitchell's conclusions were of two kinds — those resting on a basis of
stated facts, and those arrived at insensibly and irresistibly by himself during
the progress of inquiry, and founded on observations which it would be difficult
if not impossible to tabulate, or even state with precision. These inferences
may be thus briefly given, but each in its enunciation was considerably amplified
by the author.

I. That it is a law of nature that the offspring is injured by consanguinity in
the parentage.

II. That this injury assumes various forms.

III. That in all classes and conditions of society its manifestations are not
alike.

lY. That the evil appears to be in some measure under control.

Y. That isolated cases or groups of cases may present themselves where, in
addition to consanguinity, all the other circumstances are so unfavourable that
a confident prediction of much evil would be justified, yet where no such evil
appears.

YI. That, where the children seem to escape, the injury may show itself in
the grandchildren ; so that the defect may be potential when it is not actual.

Yll. That, as regards mental disease, unions between blood relations influence
idiocy and imbecility more than they do the other forms of insanity.

208

Progress of the Medical Sciences.

[July

V^III. That, with reference to Scotland, it may with safety be estimated that
about 9 or 10 per cent, of existing- idiocy is referable directly to consanguine
marriages. In forming this estimate the proper deductions were liberally made,
so as to avoid an over-statement.

Dr. Mitchell concluded by an attempt to explain the manner in which these
sad effects result from such unions. Transmissible peculiarities of all kinds are
apt to be thus intensified. If there are diseases in the parents, there are aggra-
vated diseases in the offspring ; but though the diseases may not be manifest in
the parents, they may be so increased as to constitute evident disease in the
children.— Med. Journ., March, 1862.

MATERIA MEDICA AND PHARMACY.

5. Action of Alcohol as an Aliment in Disease. — Dr. F. E. Anstie, Assist-
ant Physician to the Westminster Hospital, relates [London Medical Review,
April, 1862) four cases, one of pericarditis, two of pneumonia, and one of pleu-
risy, illustrative of the action of alcohol as an aliment in disease. ' These cases,
he states, "are by no means the only ones which I could quote from my own
practice, which might serve to throw light on the question whether alcohol does
or does not act as a food. I have selected them, because they are the only cases
of which I possess notes in which a crucial experiment was performed, viz., the
administration of no food (for none other could be retained on the stomach) but
alcohol, in the shape of wine or spirit, mixed with a little water. I think my
readers must allow that there is no imperfection in the conditions of the experi-
ments which is at all important ; and if this be so, the evidence which they
afford is very important. It may be briefly summed up thus : —

"1. Alcohol is capable of sustaining life, in the absence all other foods, for
many days.

" 2. During acute 'diseases, alcohol is sufficient, without the help of any other
food, to prevent emaciation of the body, and also the extreme lowering of mus-
cular strength, which would render the period of convalescence tedious.

"3. Given in acute disease no amount of alcohol which the exigencies of the
case require will cause inebriation ; on the contrary, delirium, unless it depend
on inflammation of the brain, may be always checked by the administration of
alcohol.

"4. That the demand of the system for alcohol in acute disease is in inverse
ratio to the power of assimilating other foods.

"To these conclusions I may add some others, to which I am led, not by the
above cases only, but by a very large number of others also.

"1. It is not true that alcohol may only be given with advantage, in acute
disease, when the skin is already moist and perspiring. On the contrary, nothing
has been more common in my experience than to see patients whose skin had
previously been dry and burning hot, break out into a refreshing sweat after
some hours of steady perseverance in the administration of alcohol in two
drachm doses every half hour.

"2. It is not true that the treatment of acute disease by large doses of alcohol
involves any danger whatever of laying the foundation of habits of drunkenness.
If the alcohol has been judiciously administered, in sufficient quantities, and yet
not too large, the moment that the appetite for ordinary food returns the desire
for the temporary substitute will cease. I fully agree with the important remarks
recently made on this subject by Dr. Druitt. It may be laid down as a rule
that, both in disease and in health, the taking of so large a quantity of alcohol
as, under the circumstances, is sufficient to produce intoxication, tends to pro-
duce a craving for the stimulus ; and it is equally certain that the timid' and
inadequate use of stimulants in acute diseases tends to produce a similar bulimia.
But the taking of even a bottle or two bottles of brandy a day, when the case
requires it, does not engender the smallest taste for alcohol after the return of

1862.]

Materia Medica and Pharmacy.

209

health. And the daily use, during health, of a quantity of alcohol which is in-
sufficient to produce any, even the earliest, symptoms of inebriation, does not
occasion the smallest craving for an increase of the dose."

6. Therapeutic Properties of the Peroxide of Hydrogen. — In our number for
January, 1861, p. 249, we noticed the interesting researches of Dr. Richardsox
relative to the therapeutic properties of the peroxide of hydrogen. Since then
Dr. Richardson has been pursuing his investigations, and in a paper recently
communicated to the Medical Society of London, he has given the results at
which he has arrived.

After repeated and long-continued experiments in reference to the different
processes for making the solution of the peroxide of hydrogen, Dr. R. has ulti-
mately come to the conclusion that no plan is so good as the one invented by
Thenard, in which the peroxide of barium is used as the agent for supplying the
oxygen, with hydrochloric acid as the displacing body. The strength of the
solution was next discussed, and it was shown that a solution charged with ten
volumes of oxygen was the best and most applicable. The dose of this solution
for an adult was from one drachm to half an ounce in a liberal quantity of water.
The compatibility of the peroxide solution with other medicines was next con-
sidered, and it was intimated that, as a general rule, the solution should be given
separately, or, if mixed with another remedy, should be so admixed at the period
of administration.

From the narration of these particulars Dr. Richardson passed in review the
results of his experience in disease. He had used the remedy now in 223 in-
stances, viz., in simple diabetes, 3 ; in diabetes complicated with phthisis, 2 ;
in chronic rheumatism, 1 : in subacute rheumatism, the continuation of an acute
attack, 2 ; in mitral disease with great pulmonary congestion, 4; in irregularity
of the heart, with cardiac apnoea, 3 ; in struma, with enlargement of the cervical
glands, 2 ; in struma, with formation of purulent matter constantly recurring,
1 ; in mesenteric disease, 1 ; in simple jaundice, 1 ; in jaundice complicated with
cardiac and hepatic disease and ascites, 1 ; in cancer affecting the glands of the
neck, 1 ; in pertussis, 9 ; in chronic bronchitis, 9 ; in bronchitis complicated
with mesenteric disease, 1 ; in chronic laryngitis, 3 ; in anaemia, 44 ; in phthisis,
first stage, 66 ; phthisis, in the second stage, 31 ; phthisis, in the third stage,
13 ; in phthisis, first stage, complicated with bronchial disease, 6 ; in phthisis,
second stage, with bronchial disease, 3 ; phthisis, with valvular disease of the
heart, 2 ; and also in a few cases of dyspepsia.

Analyzing these cases, the author came to the following conclusions : That in
the treatment of diabetes, the peroxide, while it reduced the specific gravity of
the renal secretion, increased the quantity ; so that its value in this disease was
inappreciable. In chronic and subacute rheumatism it was of great value. In
valvular disease of the heart, attended with pulmonary congestion, it largely
relieved the attendant apnoea. In struma it removed glandular swelling, like
iodine. In mesenteric disease it improved the digestion, and favoured the tole-
rance of cod-liver oil and iron. In jaundice it exercised an excellent efiect, by
improving the digestion and causing a free secretion. In cancer it seemed to
exert no influence. In pertussis its value was very remarkable ; it cut short the
paroxysms, and removed the disorder altogether, quicker than any other remedy,
except change of air. In old-standing bronchitis, during attacks of suffocative
dyspnoea, it afforded rapid relief In chronic laryngitis, its caustic character
rendered its administration painful. In anaemia, while it exerted no specific
influence per se, yet combined with iron it increased the activity of that drug.
In phthisis pulmonalis, in the first stages, it greatly improved digestion and
increased the activity of iron ; while in the last stages it afforded unquestionable
and wonderful relief to the breathlessness and oppression — acting, in fact, like
an opiate, without narcotism.

After describing the use of the peroxide in dyspnoea and epilepsy, the author
dwelt finally on the anomalous symptoms excited by the solution ; pointing out
the singular fact that in some instances where it had been pushed freely it had
produced profuse salivation. That chlorine and iodine had in these effects an
No. LXXXYIL— July 1862. 14

210

Progress of the Medical Sciences.

[July

analogy to salts of mercury was a fact long recognized; but that oxygen in the
active state exerted the same physiological action was a fact as remarkable as
it was interesting. It opened an entirely new field of inquiry. It suggested the
possibility that the salts of mercury did not act by virtue of the mercury as
mercury at all, but by the agency of the oxygen, chlorine, or iodine which they
conveyed into the organism. It suggested also the propriety of ascertaining
whether chlorine or peroxide of hydrogen might not replace mercury in cases
where it was supposed to be a specific. If this suggestion were carried out and
an affirmative were supplied, the method of cure in the disorders specified would
be rendered much more simple and rational. — Lancet, April 12, 1862.

7. Podopliyllin. — Dr. Gardner states {Lancet, March 15, 1862), that "from
1856 to the present I have constantly employed podophyllin in my practice, and
the result of my experience is as follows : —

" 1. I know no other substance which so certainly produces bilious evacua-
tions when the liver is full of bile ; I do not even except calomel ; a full dose —
namely, two grains (when pure) — producing effects very similar to those result-
ing from ten grains of calomel. I have seen jaundice, where the stools exhibited
no trace of bile and the skin and eyes were of a deep yellow, cured by a single
dose, incredible quantities of bile being evacuated. With respect to this action
of podophyllin, I think I am warranted in asserting, strange as it may appear,
that if, after a free evacuation of bile, a second dose of two grains is given within
two or three days, it produces no effect whatever, not even purging. This cer-
tainly happens in ordinary engorgement of the liver, if not in jaundice. The
purgative eftect in nearly all cases is not direct — that is, it does not act on the
bowels for ten or twelve, or even in some cases sixteen or twenty hours ; the
purging appears to result from the large amount of bile thrown into the bowels.
Sometimes its action is without uneasiness, but generally there is a sense of tor-
mina or twisting and spasmodic action in the upper region of the abdomen and
about the navel.

" 2. In the torpid liver of persons who have resided in tropical climates, a
dose of one grain seldom if ever fails to rouse the secretory action of the organ
and bring bilious coloured stools ; but it often requires twenty-four to thirty-six
hours to act on these patients. It is only at long intervals that the dose requires
to be repeated. These patients are, as is well known, accustomed to take blue-
pill, and often suffer much from nervous irritability, ulcerations of the mouth,
diarrhoea or costiveness, or both alternately, depression of spirits, and many other
evils, which all pass away after a dose of podophyllin.

" 3. In the constipation which often besets patients in phthisis — as, I think,
most frequently from fatty liver — the podophyllin is the best aperient I have
found, though, for the above reasons, very long in acting on the bowels. I have
given it in all stages of this disease with marked benefit, not obtainable from
any other purgative.

"4. I have given it much in gout, deeming it an important point of treatment
to secure free biliary evacuations, which it invariably does ; but I have not
trusted to it alone, as I think might be safely done; and the same in acute rheu-
matism. My mode of giving podophyllin has been to make it into a small pill
with soft extract of henbane, or one-eighth of a grain of extract of belladonna,
or more frequently with another concentrated vegetable resinoid — to be described
in a future paper — leptandin, either of which moderates the tendency to harsh-
ness of the podophyllin.

5. In constipation without other disorder, I usually give one-sixth to one-
fourth of a grain in a pill of compound rhubarb-pill. It acts thus very much the
same as we expect a grain of calomel or five grains of blue-pill with the com-
pound rhubarb-pill to act ; and I consider that it may in very numerous cases
be substituted for mercurials with great advantage.

" 6. Whenever I have deemed it desirable to evacuate or stimulate the liver,
as in bronchitis, fevers, headaches, &c., I have used this medicine with highly
satisfactory results.

" 7. Aware of the eulogiums which have been bestowed on podophyllin as an
alterative, anti-syphilitic, &c., I cannot either contradict or confirm them from

1862.]

Materia Medica and Pharmacy.

211

my own observations ; but I have met with two or three cases where it unequivo-
cally produced ptyalism.

" Lastly. On my recommendation it has been introduced to the Jewish Hos-
pital at Jerusalem, where liver disorders abound, and I have the general report
that it is found to justify the most sanguine expectations of its remedial value ;
and I may add, from many of my friends who have employed podophyllin, I have
received opinions confirmatory of my views."

We have been also favoured with the following : —

" Dr. Waed has administered podophyllin during the past year at the Seamen's
Hospital, Dreadnought, and in private practice in a considerable number of
cases. The affections in which he has found it useful are cardiac, renal, and
hepatic dropsies, an asthenic form of dropsy frequent amongst sailors, and not
associated with organic disease ; congested and indolent liver. He has given it
in doses of half a grain or a grain. Its action has been slow, ten or twelve hours
having usually elapsed before it has eflfected evacuation of the bowels. In the
majority of cases it has not occasioned discomfort in the way of nausea, griping,
or depression. It is less hydragogue than elaterium, but never fails in its chola-
gogue action ; producing copious bilious stools, semi-solid at first, subsequently
watery. In two other cases, Dr. Ward has found it to linger for a considerable
period in the bowels, and cause much griping and irritation ; but these results
might be obviated by quickening its action by combination with some other
drug. Dr. Ansel! informs Dr. Ward that he has given podophyllin in doses of
a quarter of a grain twice a day in cases of amenorrhcea with constipation,
and has found it act as a powerful cholagogue cathartic and emmenagogue.
The drug may certainly be regarded as a valuable addition to our materia
medica."

Dr. Ramskill, Physician to the London and Epileptic Hospitals, has favoured
us with the following valuable remarks and cases. It will be observed that his
experience of the effects of podophyllin is remarkably confirmatory of the opin-
ions of the American physicians : —

" Podophyllin may be given alone, but it is apt to gripe. At the London
Hospital I invariably order a pill of equal parts of podophyllin and extract of
Indian hemp. It is then slower of action than when given with hyoscyamus or
conium, but less frequently gripes. At the Epileptic Hospital I have not for
more than a year used any other pill as a purgative for epileptic patients, except
under special circumstances. The formula I use is extract of belladonna and
podophyllin, of each one-fourth of a grain, made into a pill with extract of mines-
permium fenestratum.^ The latter drug is rich in berberine. and is used as a
tonic adjuvant. Belladonna has itself a laxative tendency; but it is not used
for that property. One or two such pills are usually sufficient, if continued for
two or more successive nights.

"The cholagogue action of podophyllin is not confined merely to the period
of its administration ; large quantities of bile will continue to flow for several
days after ceasing its employment.

"Latterly, at the London Hospital, I have administered podophyllin in about
fifty cases a week. In three cases only has its action been seriously complained
of, the complaint being its excessive action, with pain. The dose was, in fact,
too large — namely, half a grain, all the three patients being women. Except
under such circumstances, the evacuations from podophyllin are rarely watery ;
they are always fecal at first, followed by the peasoup-like evacuations we see
follow from the continued use of colchicum, but of a brighter colour. With
•regard to the colour of feces generally, I must say that a brown colour does
not, in my opinion, prove the presence of bile, for the dark epithelium thrown
oflFin the colon may cause this ; neither does a pale clayey series prove that the
liver does not secrete bile, for this may be limited in quantity and absorbed for
well known uses in the economy. (Liebig.) But a quart or more of a golden-
yellow fluid, yielding the usual reactions to bile-tests, will often follow the use,
and demonstrate the cholagogue power, of the drug.

"Podophyllin seems to me to rank near scammony as a purgative, but it

' We shall give au account of this plant in a future paper.

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Progress of the Medical Sciences.

[July

is milder in its action. As a cholagogue it stands pre-eminent and alone — far
before mercury or any other drug that I have ever administered. I am almost
tempted to say, that there is no real cholagogue known in medicine except podo-
phyllin. Will calomel or blue-pill procure in any case an unequivocal discharge
of bile apart from its purgative or laxative action — i. e., apart from its deriva-
tive influence, accompanied by increased secretion of the small and large intes-
tines ? Is not this the mode in which the biliary secretion is liberated by these
mercurials? Podophyllin, on the contrary, in very small doses, will procure an
abundant flow of bile, and often induce its discharge by vomiting, before, or even
sometimes without, any purging. My idea respecting the modufi operandi of
mercurials is supported by very good authority — [vide Morehead, On the Dis-
eases of India)."

8. Therapeutical Properties of Malt. — M. Fremy has made use of malt as a
remedial agent. That prepared by Nitsohke, a brewer near Berlin, he has found
to be of superior quality to that obtainable at Paris ; it is more soluble, aroma-
tic, and agreeable. The malt-powder may be given internally in the form of
decoction, and applied externally by means of baths. The substance was tried
on sixty-four subjects of well-marked phthisis ; but the results were trifling,
beyond a certain degree of temporary amelioration. It was, however, of greater
service in cases of chronic bronchitis, early phthisis, and chronic pulmonary
catarrh — its utility being very marked in this last affection. In simple dyspep-
sia it is of use when the saburral condition of the tongue has been removed. In
Germany it has been found to be of great advantage in the chloro-anaemia of
nurses. " The powder is a true analeptic, and the bitter principle, which it
owes to the presence of lupulin, renders it very efficacious in re-establishing the
functions of the stomach in dyspepsia." — 3Ied. Times and Gaz., March 15, 1862,
from Journ. de Chimie Med., Feb.

9. Substitution of Daturia for Atropia. — For some time past M. Jobert
has substituted for the preparations of belladonna a solution of daturia as a
mydriatic. He finds it is three times more powerful than atropia, and can
therefore be employed in proportionally less quantities. It does not produce
pain when introduced into the eye, nor does it confuse vision like belladonna,
while its effects are more constant and its action more persistent. — Bull, de
Therap.

10. Antiseptic Properties of Ammonia. — Dr. Richardson, in a paper read
before the Medical Society of London, states that his earliest researches were
directed to the study of the antiseptic properties of gases, and recalled attention
to the communication he had made to the Society on this subject in 1850. His
present inquiry and application of ammonia as an antiseptic commenced in 1858.
His attention was then directed to the fact, that the presence of ammonia effec-
tually arrested the oxidation of various bodies, and even prevented the action
of ozone. Believing that by an extension of the same law animal substances
exposed to ammonia could be prevented from putrefaction, he kept blood and
portions of tissues in contact with simple ammoniacal vapour, and with results
which were most remarkable. Blood in an ordinary stopped bottle, if charged
with ammonia so as to give a faint ammoniacal odour, would retain its freshness
and many of its properties for years. Animal structures in like manner placed
even so as to be massed together in bottles containing ammonia vapour, would^
retain their freshness for an unlimited time. Dr. Richardson now showed the*
following specimens : The lungs of a calf which he had used for lecture purposes
for six months, and which had been simply placed under a bell-jar, a little
ammonia in solution being put over them from time to time ; a pancreas which
had been kept for eighteen months in a bottle containing twenty minims of
ammonia solution ; a kidney showing deep congestion, which had been removed
sixteen weeks ; a bottle of mixed specimens, including portions of intestine with
enlarged glands ; a bladder, the inner surface of which was injected ; a uterus
and ovaries and a pancreas, all of which had been preserved lying close in one
bottle for sixteen weeks ; also a portion of liver, which had been removed nearly

1862.]

Materia Medica and Pharmacy.

213

three years ; and a cancerous breast, which had been removed by Mr. Spencer
Wells eight weeks before. The specimens all retain their freshness, and ad-
mitted of dissection and examination as in the recent state. The author then
described the method of applying ammonia. It was necessary, in the first place,
to trust to the ammonia alone : specimens that were exposed first to spirit and
then to ammonia vapour were always spoiled. For the preservation of fluids,
such as blood or milk, it was merely necessary to add the alkali in solution in
proportion, say of twenty minims, of the strong solution to two ounces of the
fluid to be preserved. For tissues the plan was to place the specimen to be
preserved in a stoppered bottle or under a bell jar, such as is used for wax
flowers and ornaments, to place in the jar with the specimen a layer of felt or
lint, charged with from ten minims to a drachm of the liquor ammonia fortis,
and then to close the vessel or jar secure from the external air. For a luting
in such cases soap answered best, or a mixture of soap and red lead. After this
description, Dr. Richardson pointed out the practical value of the method. 1st.
In conducting post-mortem inquiries it did away with all occasion for hurry. It
was now only necessary at an autopsy to be provided with one or more jars,
each containing say a drachm of liquid ammonia. The jars might now be filled
with specimens, and if the stoppers were put in with care the specimens would
retain their freshness for weeks, and even their microscopical characters. The
only peculiar change was, that if much fat were present, the alkali formed with
it a kind of soap ; a fact which explained the formation of adipocire in the dead
subject undergoing slow decomposition. For forensic purposes this method of
preserving animal structure was perfect, inasmuch as it added no mineral or
poisonous matter, and yet secured the part to be examined free from change
and from all offensive odour. Not only so, but important pathological changes,
such as ulceration of intestine, could be kept under observation and submitted
to any number of pathologists. He (Dr. Richardson) had found the system a
very useful one, too, for lecture purposes, as it enabled him to show to his class
real specimens of disease, such, for instance, as the scirrhous breast now going
round, instead of casts or specimens softened, discoloured, and, indeed destroyed
altogether by immersion in spirit. The last point to which Dr. Richardson
drew attention had reference to the cause of the antiseptic power of ammonia.
Ammonia being a product of decomposition had been looked on commonly as a
substance provoking decomposition. But ammonia was truly the most powerful
antiseptic known : it acted catalytically by preventing the union of oxygen with
oxidizable bodies. An experiment was here performed illustrating this : half a
grain of ammonia diffused through 40 cubic inches of air was shown to possess
the power of entirely suspending the combination of oxygen with potassium on
a surface of paper saturated with iodide of potassium, starch, and solution of
oxygen, so long as the paper was presented to the ammoniated air ; but so soon
as the paper was removed, the evidence of the combination, indicated by the
■formation of the blue iodide of starch, was presented. In preserving animal
structures in ammonia, the same experiment was virtually carried out ; the
presence of the ammonia suspended the oxidation. There were other agents
which effected the purpose, such as chloroform ; but the fact that these agents
were indifferently soluble in water rendered them much less effective as com-
pared with ammonia, which combined readily with the water contained in the
tissues, and so perfected the preservation to the minutest point. In conclusion,
the results presented tended to throw a light on the influence of the ammonias
as the producing causes of some diseases, and as the curative remedies in other
diseases. The same rule that pertained to dead pertained to living organic
matter. Hence long exposure to ammoniacal vapour, by arresting oxidation,
produced extreme anaemia and a low depraved condition of the system, alto-
gether with reduced respiration, reduced appetite, reduced muscular power, and
reduced energy. On the other hand, in cases where a rapid oxidation of the
body was being determined attended with increase of heat and rapid disintegra-
tion of tissue, the administration of ammonia, by arresting these changes, be-
came in judicious hands the most powerful and effective of remedies. It checked
decomposition by its action on oxygen ; it held the blood fluid by its solvent

214

Progress of the Medical Sciences.

[July

power as an alkali, and being volatile it inflicted no immediate injuries on the
structures of the body. — Med. Times and Gazette, May 10, 1862.

11. Inhalation of Pulverized Fluids. — M. Poggiale recently read to the
Academy of Medicine an extremely elaborate report on the much disputed ques-
tions connected with the inhalation of pulverized fluids. The various papers on
the subject were so conflicting, their contradictions were so glaring, that it
became an imperative duty for the Academy to ascertain with precision the
amount of practical utility of this new method of therapeutic ministration. M,
Poggiale began by establishing the fact that the authors who have inquired into
the subject cannot agree as to the penetration of the pulverized fluids into the
respiratory passages, and are at utter variance with each other, with regard to
the refrigeration of the liquids operated on, the waste of the mineralizing ingre-
dients of pulverized sulphurous water, and the medicinal effects of M. Sales-
Girons' method ; he then carefully examined in succession all the elements of
these intricate problems, and concluded as follows : —

The experiments on animals and on the human subject, instituted by MM.
Moura-Bourouillou, Tavernier, and Demarquay, the researches of M. Fournie,
On the Introduction of Pulverized Substances into the Air-passages," demon-
strate, beyond contradiction, that liquids reduced to spray actually penetrate
into the respiratory ducts.

On leaving the apparatus, pulverized fluids undoubtedly undergo some degree
of refrigeration ; but, in a letter to the academy, M. Tempier states that this
unfavourable circumstance may be neutralized by causing the spray to be emit-
ted in an atmosphere saturated with steam, at a temperature higher than that
of the pulverized water.

With regard to the chemical changes induced by the method in sulphurous
waters, M, Poggiale, while admitting their existence as a general fact, asserts
that they are not the same for all waters of this kind. Thus, the waters of
Enghien, which contain free hydrosulphuric acid, lose on an averege 60 per cent,
of that ingredient. The waters of the Pyrenees, on the contrary, in which sul-
phuret of sodium is to be found, are very slightly modified in the process in
question. It would also appear that the waste of the sulphurous element is less
considerable with M. Sales-Girons' apparatus than with M. Mathieu's instru-
ment.

The desulphuration is, in all cases, greater in proportion as the procedure is
carried on at a more considerable distance from the spa, and the changes are,
therefore, more obvious in the inhalation-rooms than when portable instruments
are used.

Another highly important question requires an answer. Is it possible, with
the data in our possession, to describe with precision the therapeutic effects of
the inhalation of pulverized fluids ? To this query the commission experienced
much difficulty in framing a reply; thus, on the one hand, MM. Sales-Girons,
Auphan, and Demarquay, assert that they have derived much benefit from the
inhalation in chronic affections of the respiratory organs, and on the other hand
Professor Champouillon and MM. de Pi6tra-Santa, Brian, Delore, and Fournie,
utterly deny the efficacy of the method. M. Poggiale confined himself, there-
fore, with undisguised regret, to an appeal to further inquiry, and moved that
the thanks of the Academy be forwarded to the experimentalists above named,
who have spared no efforts to dispel the clouds which obscure the question. —
Journ. Pract. Med. and Surgery, also Gazette Hehdom., 10 Jan. 1852.

12. Administration of Cod-Liver and other Oils. — Dr. Alexander Wallace,
Physician to the Metropolitan Free Hospital, has instituted a number of experi-
ments with a view of determining the best formula for the administration of
oleaginous substances. Starting with the proposition that the digestibility of
these substances depends, 1st, on their dilution ; and 2d, on their minute sub-
division in a convenient menstruum, he tried various admixtures ; and recom-
mends as the best equal parts of liquor calcis and oleum morrhuse. These, he
says, when well shaken together, do not subsequently separate readily, but re-
main in the form of an emulsion, thick and of a milky hue.

1862.]

Materia Medica and Pharmacy.

215

"Here," says Dr. W., "in addition to the tonic and sedative action of the liq.
calcis (in itself so well suited to the many forms of disease in which cod-liver oil
is recommended), a white-coloured, light, very palatable medicine is obtained
(perhaps somewhat less disagreeable in its odour than the pure form, owing to
the deodorizing action of the liq. calcis), easily rolling over the palate, and,
when taken with a little sherry or orange wine, almost devoid of the oily taste,
and combining, perhaps in the highest degree of all formulae that I have as yet
tested, the advantages of the mode of administration which I now advocate.

" The addition of a few drops of Condy's fluid to the mixture of liq. calcis and
ol. morrhua3, sufficient only to render it of a greenish-yellow tint, rendered it a
little less odorous, and, perhaps, more palatable. I am unable to say whether
such addition would ozonize the oil, and thus render it more beneficial. The
advantages gained by the mode of administration in other menstrua are : —

" 1. The minute subdivision into globules, rendering it thereby more palatable,
easily swallowed, and less likely to adhere to the mouth and fauces.

"2. A saving to the stomach of the labour of disintegrating and minutely
subdividing the oil, similar to that effected by the teeth in the trituration of
solids, both ingesta being thus rendered easy of digestion and assimilation.

" 3. The admixture of air-bubbles with the food is believed by many physio-
logists to assist digestion ; this occurs to a very great extent during the shaking
of the medicine, which should always be performed in a separate bottle at least
twice as capacious as the dose, previous to its being taken.

"4. It may be possible that the friction of the globules during the shaking
may develop a portion of electricity in them, giving thereby a tonic character ;
but this I leave to electrologists to determine.

"The microscopic characters of the mixture of liq. calcis and ol. morrhuae,
recently shaken together, are as follows : Oleaginous globules in a minute state
of subdivision, pellucid, of a pale violet tint, many of them as small as milk glo-
bules, but many of larger size, having but little tendency to run together into
larger globules, with numerous air-bubbles intermixed." — Med. Times and Gaz.,
April 19, 1862.

13. NeiD Preparation from Gliloroform. — Dr. Thomas Skinner, of Liverpool,
calls attention to two physical properties possessed by chloroform, viz : 1. Its
solubility in alcohol, and subsequent miscibility in water. 2. Its miscibility, if
not its solubility, in water.

Lately, while engaged experimenting in order to ascertain the probable com-
position of Davenport's chlorodyne, Dr. S. accidentally discovered the following
valuable facts : —

" 1. If chloroform be dissolved in rectified spirit of wine, of specific gravity
.838, at 60^ Fahr. (L.P.), in the proportion of from one to sixteen minims of chloro-
form in a fluidounce, the resulting liquid is entirely and freely miscible with
water in all proportions. On adding minim by minim of chloroform to the
measure of thirty or thirty-two minins to the ounce of the mixture, the solution
ceases to be miscible with water in any proportion : the chloroform sponta-
neously precipitating in small globules, which ultimately coalesce.

-"2. If chloroform be added to distilled or any good drinking water, in the pro-
portion of half a fluidrachm to a pint (twenty fluidounces), and briskly agitated,
the resulting liquid is perfectly clear and bright, and no globules of chloroform
are precipitated, nor can any be detected with the microscope by a power
equal to 250 diameters. On adding more chloroform gradatim, the point of
saturation is not arrived at until the proportions are a fluidrachm to a pint of
water. Sixty-four minims to the pint render the mixture quite opalescent, and
much of the chloroform is precipitated. At the point of saturation, a drop of
any essential oil shaken with the mixture will determine the separation of the
chloroform. If the whole fluidrachm of chloroform be added at once to a pint
of water, and shaken, the resulting liquid will not be so clear as when it is added
gradually.

"Bearing these interesting facts in mind, I resolved to put them to some prac-
tical use ; and I beg to suggest the propriety of there being two new officinal

216 Progress of the Medical Sciences. [July

preparations of chloroform, the names and formulae for which shall be as fol-
lows—

" Spiritus Formyli Terchloridi (commonly called chloric ether) : Chloroform.
5v ; rectified spirit of wine, sp. gr. .838 (L. P.), Oj. Mix. Dose, ^ss to gij.

Mistura Formyli Terchloridi (or chloroform julep) : Chloroform, 3ss; pure
water Oj. Mix thoroughly with brisk agitation, for a minute or two, in a vessel
capable of containing double the quantity. Dose, .f ss to ^ij.

" Either preparation may be prepared from the methylated chloroform ; but
hitherto I have preferred the unmethylated for administration by the 'prima via.
A chemical nomenclature has been chosen, in deference to the possible and not
improbable fears of the patient." — DuUin Med. Press, May 21, from Brit. Med.
Journ.

14. Vesicating Collodion. — Mr. C. R. C. Tichborxe remarks {Pharmaceutical
Journcd) that " amongst the many epispastics which have been introduced from
time to time, cantiiarides has remained pre-eminent — its certainty, and compara-
tive freedom from pain, being its special commenders. As direct and prolonged
contact with the skin is necessary to produce a vesicle, many substances have
been in use as an excipient for the application of the vesicant. Some of the
preparations in use at present are fluid, whilst others are applied- in the form of
plaster or ointment. In the first instance, if the desired effect is not produced
instanter, rubefaction is the only result, an insufiScient amount being left upon
the surface to produce a blister. Vesicating collodions are preparations which,
after evaporation, leave a thick coating upon the cuticle, containing a certain
quantity of irritating principle : these may be considered in their actions as
intermediate between the fluid and solid preparations, combining, as they do,
the properties of both. It is our especial vocation on the present occasion to
take into consideration the construction of a formula for the collodium vesicans.
This preparation, although constantly used by some very extensive practitioners,
is far from being generally introduced, which may be accounted for from the
circumstance that there is no authorized formula for its preparation, if we
except M, Altigner's cantharidal ether and collodion, one to two parts of the
latter for children. Each maker has then his own formula, which might be
excellent, or vice versa, as the case may be. It will be our endeavour to pro-
vide a formula which shall have suSicient strength to produce immediate vesica-
tion, at the same time having a due regard to the economy of the method. To
insure prompt action, it is not only necessary to introduce a sufficient quantity
of blistering material, but it is also requisite that the excipient, or film in which
it is applied, should be permeable enough to allow the active principle to transude
freely through it. The tough and contractile film left by the ordinary collodion
is almost worse than useless, as immediately on drying, the cantharidin at the
surface and in direct contact alone exerts any beneficial effect ; an ordinary
blister might be applied for any length of time, without producing a sensible
result, if a dry film of plain collodion be interposed between the blister and the
cuticle.

"First, then, let us examine the texture of a collodion film, to mark its appli-
cability in the present case. If we pour upon a glass slide some recently pre-
pared collodion, and then examine it by the microscope, it will present the fol-
lowing appearance: A pretty homogeneous and smooth ground, but running
through which are slight ridges, which produce large honeycomb markings.
These ridges are caused by the quick evaporation of the ether ; the whole is
interspersed with filaments of partially disorganized cotton in a semi-gelatinous
state. However carefully the cotton may be prepared, it is next to impossible
to get rid of these fibres, some portion always escaping the perfect action of the
acids. If we can add a small quantity of glacial acetic acid to the collodion, we
shall find the character of the film greatly changed. From the slower evapora-
tion the honeycomb ridges are no longer palpable, whilst the solubility is so
much increased that the filaments are found to have disappeared. This film is
perfectly uniform, but it presents this peculiarity, that it gradually dries into a
muss of jelly like globules, which, however, possess but little cohesion ; when
dry, it is very short, for if the finger be run up the glass, instead of leaving it as

1862.]

Materia Medica and Pharmacy.

217

a tougli skin, it collects as a moist crumbled mass. Having- so far seen that
the glacial acid, besides destroying the contractility, gives it the properties of
porosity and slowness in drying, it follows that such a collodion is particularly
suited for the application of any vesicant which- we may intend to apply, instead
of being a varnish which hermetically seals up the active matter. Glacial acetic
acid is one of the best direct solvents of cantharidin with which we are acquainted.
Pure cantharidin was found to be very soluble in that acid, a saturated solution
depositing it unchanged on evaporation in hard mica-like crystals. The prin-
ciple then that we propose is, to exhaust cantharides by a mixture of ether and
acetic acid, and to convert these into a collodion by the addition of gun-cotton.
Take cantharides ,^vj ;' Ether from methylated spirits f^xiij, or q. s. ; Glacial
acetic acid f^ij ; Gun-cotton ^ss; Methylated spirits of wine f^vij, or q. s.

" The cantharides, coarsely powdered, are placed loosely into a displacement
apparatus, the flow of which can be regulated by a tap ; upon this is poured the
ether and acetic acid, previously mixed together ; after the whole lias passed
through, it will be found that the debris has retained by absorption seven fluid-
ounces, which must be displaced by the gradual addition of an equal bulk of
methylated spirits. If properly done, there is not the least danger of the ad-
mixture of the spirits with the percolated menstruum, as the animal substance
of the flies swells considerably under the prolonged influence of the spirits of
wine, so that the same bulk will be insufficient to quite displace the ether. The
ethereal solution should then be made to measure exactly f Jxv, by the addition
of a little spirit, and may then be converted into collodion by the addition of the
gun-cotton. Mylabris cichorii, treated in the same manner, gives even a more
powerful vesicant than the cantharides. These flies, which constituted the
iDlister of the ancients, are, I believe, to be procured in great profusion in India.
The percentage of cantharidin is larger in these flies than in the cantharides,
but they resemble them in all respects excepting their physical appearance.

The most effectual method of using the collodion is as follows : The part
upon which the vesicle is to be raised should be painted with the vesicant to
the desired extent, bearing in mind that the blister produced always extends to
about one-tenth of an inch beyond the margin of the space covered by the col-
lodion. Care should also be taken that there is a considerable thickness of
collodion upon the surface. To insure this the brush should be passed over
and over again until about gss has been used to the square inch, or less when
operating upon a tender epidermis. It is desirable to place a piece of oil-silk,
or, what is still better, a piece of sheet gutta-percha, two or three inches larger
than the surface of the intended blister ; the gutta-percha is not spoiled, whilst
it hastens considerably the action of the collodion.^

"In ten minutes, or a quarter of an hour if the cuticle is hard, the collodion
should be wiped off with a little cotton-wool moistened with ether, when the
blister will almost instantly rise. The principles which advocate the use of the
collodion may be enumerated as follows : Cleanliness, ease in applying to any
wrinkled or jointed part, where the ordinary blister would be likely to be dis-
placed, prompt vesication, and safety from strangury. Any of these properties
would be sufficient individually to recommend its employment in preference to
the- other preparations."

15. Solid Creasote. — M. Stanislaus Martin remarks [Bulletin Generale de
Tliiraideidique) that creasote is much employed as a popular remedy in the
case of pain produced by caries of the teeth, but as the fluidity of this product
is very great, its use often causes, in the mouth of persons using it, effects of a
serious nature, which might be avoided by solidifying it in the following man-
ner ; R. — Creasote, part xv ; collodion, part x. M.

^ Two ounces more cantharides to tlie above proportions, make a very powerful
collodion.

2 The action of the gutta-percha is easily explained, by its stopping the evapo-
ration of the exhalations of the skin ; in this manner the scarf-skin is rendered
moist and permeable, the ordinary dry and harsh texture of the skin militating
greatly against the production of a vesicle.

218

Progress op the Medical Sciences.

[July

The collodionized creasote has the consistence of jelly, and is used in the
same manner as the simple substance. It has, however, this adrantao-e, that it
forms a varnish, seals up the orifices in the carious tooth, and prevents the
atmospheric air from reaching the dental nerve,

Creasote is known to coagulate albumen, and it is probably to that property
that its astringent and haemostatic action is due. "We think that the new form
which we have given to this substance will allow surgeons to use it whenever
they wish for a stimulating agent combined with isolated action. — Glasgow
Medical Journal, April, 1862.

16. Inefficiency of Hyoscyamus as nsnally prescribed. — M. Doxovax thinks
that unnecessary caution is taken by physicians who administer tincture of
henbane in doses of one or two drachms. He and some other persons have
each taken an ounce of the tincture without any effect, the tincture having been
prepared from the plant in its cultivated state, its wild state, dried, recent, and
grown in various places in the British Isles. M. Hirtz informs us [Bull. G6n.
de Th^rap.) that the extract of the leaves of hyoscyamus was given to patients
in the dose of 50 to 75 centigrammes a day with results only slightly marked,
and even these rather inconstant; a gramme (15.43 Troy grains) was sometimes
given without any observable effect.

In order to compare this result with his own. jSE. Donovan evaporated one
ounce of the tincture (the same as had already served for his former experiments)
until it assumed the usual consistence of extract of hyoscyamus. The evapora-
tion was conducted at a very low heat, and the weight of the extract ascertained
with great care ; it weighed 8.4 grains. This is very little more than the half of
the dose of the extract which M. Hirtz administered without any observable
effect. "I might, therefore," says Dr. D., "have made the dose of the tincture
taken by myself and friends at least two ounces without any discoverable result.
If two ounces had no effect, three ounces could not have much, unless it produced
intoxication. In fine, I venture the opinion that tincture of the leaves of hyos-
cyamus should be expunged from the Pharmacopoeia. Those physicians who
venture on two-grain doses of extract of henbane will learn with interest that
M. Hirtz gave fifteen and a half grains without any effect. His were clinical
experiments, and therefore afforded the best opportunities for observation. I
believe the case would be very much otherwise if the seeds were used instead
of the leaves."— Dw&. Ifed. Press, May 28. 1862.

[It is difficult to reconcile this statement with the case communicated by Dr.
Keating to the Philadelphia College of Physicians (see number of this J ournal
for July, 1858, p. 96), in which very profound and alarming narcotism followed
the administration of three grains of Tilden's extract of hyoscyamus, or, at
least, what was sold and labelled as that article.]

MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL

MEDICINE.

17. On the Exhibition of Food in Typhoid Fever. By M. Herard. — The
following remarks made by M. Herard. in a clinical lecture at the Hotel Dieu,
at Paris, are of particular interest at the present time, especially to the medical
officers of our army hospitals : —

" The treatment of typhoid fever is of course different according to the theory
adopted on the nature of the disease. The practitioner who views in typhoid
fever follicular inflammation of the intestinal tube, an ulcerous affection of
Peyer's glands, and consequent absorption of poisonous fluids calculated to
induce a septic condition, consistently prescribes antiphlogistic remedies in the
incipient stage, and tonics in the more advanced period of the disease. Like-
wise, those who conceive that the decomposition of the local secretions is the
primary cause of the infection of the system act consonantly with their theory

1862.]

Medical Pathology and Therapeutics.

219

in systematically exhibiting emeto-cathartics and laxatives. In these opinions,
however, M. Herard does not participate ; while taking into serious account
the intestinal eruption, which, like that of smallpox, induces a certain amount
of circumambient inflammation, he cannot admit this to be the proximate cause
of typhoid fever. No concordance can be traced between this anatomical change
and the general condition of the patient, the gravity of which must be acknow-
ledged to be entirely independent of the local injury. Hence the latter cannot
be taken for a guide in the choice of the medication most appropriate to a fever
in which the collapse of vital power and the obvious tendency to hemorrhage
and mortification point most distinctly to a primary alteration in the composi-
tion of the blood. M. Herard does not deny that an emeto-cathartic may be
proper to remedy the foul state of the primse vise, so common in the early stage
of typhoid, but he can neither concede to aperients, to venesection, nor to local
bloodletting, the privilege of being the exclusively appropriate modes of treat-
ment of the disease.

" In typhoid fever M. Herard proceeds as follows : —
In moderate, and a fortiori in mild cases, he refrains from any active inter-
ference calculated to debilitate the patient, and to cause the disease to assume
the dangerous form which justly occasions so much dread. M. Herard pre-
scribes an emeto-cathartic, one or two doses of saline aperients, a few baths if
the skin be very hot and dry, and wine and water. Baths restore the functions
of the skin, and usually induce sleep. In the adynamic variety he resorts to
tonics, stimulates the system with Malaga or Bordeaux wine, either in drinks
or in enemas, prescribes from half a drachm to a drachm of powdered cinchona
bark, in cofi*ee without milk, and also recommends various stimulants, such as
musk, camphor, acetate and carbonate of ammonia. He causes, at the same
time, the eschars to be covered with powdered Peruvian bark, and requires from
the nurses the most strict attention to cleanliness. In the ataxic form, the most
fatal of all, bloodletting, leeches, blisters, are unavailing; all remedies seem
powerless. In order, however, not to appear entirely inactive in cases of such
dire gravity, he prescribes stimulants, dry cupping of the extremities, blisters
to the nape of the neck, and cold effusions cautiously administered. In the
thoracic form, which this year has been the most prevalent, blistering and cup-
ping, with scarification, are the remedies which M. Herard has chiefly resorted to.

" The above is a brief summary of the treatment appropriate to typhoid ; but
in the management of the disease the all-important, the capital question is that
of food.

" Despite the wise precepts of Hippocrates, said M. H6rard, despite the recent
researches which have only confirmed their value, we are still all more or less
influenced by the now exploded doctrine of irritation. The terms fever and
food still appear to imply a contradiction, although it is but too certain that in
typhoid prolonged abstinence leads to the most disastrous results.

" Some ten years ago, M. Herard was in attendance on a lady sufi'ering from
a moderately violent attack of the malady under consideration. Cerebral
symptoms having set in, a consultation took place, and an eminent professor of
the school of medicine recommended absolute abstinence from food, and the
daily exhibition of one or two glasses of seidlitz water. The latter part of the
prescription M. Herard took upon himself in some degree to modify, but the
abstinence was strictly enforced. After two or three weeks' treatment the pulse
rose from 110 to 120, nocturnal agitation set in, with wandering, delirium, vomit-
ing, and diarrhoea. On the following days the frequency of the pulse increased
to 145, vomiting became incessant, the diarrhoea incoercible, the delirium con-
stant ; the tongue was red, and thrush appeared over the entire mucous lining
of the mouth. Another consultation was deemed expedient ; the three gentle-
men whose opinion was requested viewed the case in a different light. One
pronounced the patient to be suffering from softening of the stomach ; the
others, struck by the pinched countenance, the emaciation of the entire body,
and the cough which had set in in the incipient stage of the disease, believed in
galloping consumption, and proposed cod-liver oil. M. Herard, who had long
been acquainted with the patient, found it impossible to adhere to any of these
views, and, moreover, unable to venture, under the existing circumstances, on

220

Progress of the Medical Sciences.

[July

the exhibition of cod-liver oil, surmised that the previous protracted abstinence
might possibly have some share in the aggravation of the symptoms, and deter-
mined upon trying the effects of nutriment. He found it almost impossible at first
to carry out this plan, and it was vp^ith the utmost difficulty that a few drops of
iced beef-tea were swallowed. He succeeded by dint of perseverance, however;
and when the food remained on the stomach, and in proportion to its increase,
the pulse fell from 145 to 130, 120, 115, and 100 ; the delirium yielded, and, in
short, the patient recovered.

" M. Herard is convinced that similar cases are of not unfrequent occurrence,
and that the dangerous symptoms of the ataxic form of typhoid are often induced
by the strict abstinence previously enforced. In a highly interesting paper on
the subject, M. Marotte has established that vomiting, diarrhoea, and delirium,
more especially the latter, are characteristic of starvation. In a lecture recently
published, M. Trousseau already pointed out the striking analogy existing be-
tween the more serious symptoms of typhoid and those of autophagy consequent
on protracted abstinence. The valuable experiments of M. Chossat may further
be adduced in illustration of the theory which accounts for this extremely im-
portant fact, and must lead to a complete change in the treatment of typhoid
fever.

" The expression we advisedly use is treatment, not diet. Nutriment here
must be viewed not as an adjuvant, but as the principal medical agent. It has
been objected that if food be exhibited, indigestion and emesis must follow.
This is correct after protracted abstinence, and proves the necessity of early
alimentation, otherwise the digestive powers of the stomach become impaired
and the food is rejected. Opponents of the method further urge the impossi-
bility of venturing on the exhibition of nutriment, on account of the deposits
which necessarily exist on the mucous surface of the stomach, and poison the
breath of the patient by their decomposition. Now these deposits are frequently
but one of the consequences of abstinence, and if the tongue and gums are
cleansed with a brush impregnated with honey of roses or syrup of mulberries,
the sores do not form again after the ingestion of food. M. Herard had recently
under his care, at Lariboisiere, patients who have fasted for three weeks, and
who displayed marked distaste for any kind of nutriment. The gums were
covered with sores, the breath was foul ; but after cleansing the mouth and
scraping the tongue, food, which these patients were compelled to take, pro-
duced its usual salutary effects, and in a few days was accepted with pleasure
and with the most beneficial results. M. Marotte relates the case of a young
man, aged twenty, who, at first compelled to eat, soon took his food with plea-
sure, and ultimately recovered in an unhoped-for manner. The propriety of
feeding patients suffering from typhoid has also been questioned in another re-
spect ; the presence of intestinal ulceration, of tympanitis and diarrhoea had
been viewed as a direct counter-indication to the exhibition of nutriment, and
as the probable cause of the most perilous symptoms in case this method was
resorted to. This fear is entirely chimerical. You must not, moreover, forget
that the cachectic condition of the patients is the greatest possible obstacle to
the healing of the ulcers, and that the latter are portals through which poison-
ous principles will most readily be admitted. Subjects affected with intestinal
ulcerations should be fed, and the ulcers, nevertheless, decrease in size, and heal
In the same manner as bed-sores, so common under similar circumstances, yield
to the influence of generous diet. Some short time ago, a woman was admitted
into the H5tel-Dieu, on the twentieth day of a typhoid fever complicated by
extensive mortification in the region of the sacrum. Nutriment, appropriate in
nature and in quantity, was gradually exhibited, and the wound speedily lost its
pale aspect, assumed a more healthy hue, granulated, and healed. Had absti-
nence from food been here persevered in, she would very probably have perished ;
but a contrary course was followed, and she recovered rapidly. Another bene-
ficial effect of nutriment is to shorten the duration of the convalescence^ which
formerly was interminable after putrid fever. Patients, who have received ade-
quate support during the progress of typhoid, have been known to pass without
any transition from disease to health, and to walk in the garden of the hospital
on the very first day they left their bed.

1862.]

Medical Pathology and Therapeutics.

221

" It is not unimportant to inquire what should be the nature of the nutriment
allowed. It was formerly the custom to exhibit food when only the feverishness
had subsided, and it sometimes unfortunately happened that the delay was so
long as to render the food superfluous. Other practitioners prescribe broth,
under the impression that broth is sufficient support to the system. Broth is
doubtless a nutrimental substance ; we are all acquainted with its restorative
powers, but we must not exaggerate its value. M. Bouchardat demonstrates
that a quart of broth contains but six drachms of solid nutriment, two of which
are saline ingredients ; subtract from the remaining four drachms a certain amount
which passes through the kidneys, and you will doubtless agree with me that the
residue affords but insafiicient support to the system.

" M. Herard proceeds then to describe his mode of administering food in
typhoid. Soups are, in his opinion, the best articles of diet; egg-flip is often
useful, and contains a large proportion of nutriment especially applicable in the
thoracic variety of the disease. Jellies are also advantageous, and when, on
account of their volume, soups are not easily digested, the professor, even at an
early period of the fever, does not hesitate to recommend the suction of a mutton-
chop. Patients, whose stomach rejects the weakest broth, frequently digest
with facility a small piece of broiled beef or mutton. He is no friend of the
debilitating tisanes and diet-drinks usually prescribed, but agrees with M. Mon-
neret in the utility of wine, as a stimulant of the vital powers. The beverage
he recommends is weak wine and water, and, in addition, eight ounces of Bor-
deau or bark wine, to be taken in enemas if necessary. When the digestive
powers of the stomach have been much impaired, he conceives that pepsine,
acting as a kind of ferment, promotes the assimilation of the food and gives the
gastric viscera time to recover their secretive action, the patient, in the mean-
while, not suffering from the efiect of injurious abstinence. Fifteen grains of
pepsine may therefore be exhibited in a wafer with animal food.

" In addition to these physical restoratives, M. Herard has recourse to moral
agency. The greater numlDer of individuals sufifering from typhoid fever in the
hospitals are young people of both sexes, not only strangers in Paris, but often
foreigners. Their isolated condition, combined with the knowledge that they
are labouring under serious illness, has much to do with the low condition into
which they speedily fall. Hence the importance of encouraging such patients
by a kindness of manner and of language calcukted to improve their moral
condition, and to counteract the unfavourable influence exercised upon their
system by the distressing circumstances under which they happen unfortunately
to be placed." — Journ. Pract. Med. and Surg., May, 1861.

18, Quinine as a Prophylactic of Fever. — The powers of quinine as a pro-
phylactic, remarks Dr. Smart, in his account of the climatology, etc., of Hong-
Kong, were proved extensively among the crews of the gunboat flotilla employed
oh the Canton Kiver. Although those little vessels were constantly on river
service, often remaining the night with their bows driven on the mudbanks, their
crews sleeping on deck in preference to the close heated atmosphere of 'tween
decks, having no medical officer on board, and thus receiving merely an eleemo-
synary medical supervision from the larger men-of-war they came near, yet they
seemed not to suffer disproportionately from malarious fevers, excepting those of
the intermittent type. Their comparative exemption I considered to be due to
the abundant supply of quinine wine ordered for them by the medical inspector
of the fleet. On the slightest occasions of indisposition they had. recourse to
their commanding officers, who held the quinine bottle at hand, in the preventive
and curative powers of which the seamen seemed to have the utmost confidence.
— Trans. Epidemiolog . Soc. of London, May, 1861.

19. Clinical Inquiry into the Use of Iron in Pulmonary Consumption. — In
our No. for April last (p. 523) we gave results of the clinical trials by Dr. R.
P. Cotton on the action of steel in phthisis.

More recently {Bled. Times and Gazette, March 22, 1862) Dr. James Jones,
Physician to the Infirmary for Consumption, in Margaret Street, has published
the results of his clinical observations on the same subject.

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Progress of the Medical Sciences.

[July

Passing over the writer's physiological and pathological speculations, we shall
give his practical deductions as of most importance.

" The mode of administering iron in phthisis'' Dr. Jones conceives to be "a
subject of the greatest importance to its success as a remedy. In prescribing it
it is necessary that we should bear in mind the object to be accomplished by its
exhibition, the supply of the deficiency of one of the normal elements of the
blood. We must give iron as a blood food, carefully regulating the quantity by
the requirements of that fluid. When iron is given in over-doses it soon induces
headache and derangement of the organs of digestion. There is nothing more
common than to hear from patients that steel has always disagreed with them.
This intolerance of iron may generally be referred to two causes : Firstly. The
unfitness of the preparation. Secondly. The excess of the dose.

"With regard to the first of these points it is important that the preparation
of iron which is used should have the following qualities : First. Perfect solu-
bility. Second. A composition in harmony with the digestive fluids, the blood,
and the other fluids of the body. Third. Compatibility with such drugs or medi-
cines as may be required by the varying phases of the disease. The perchloride
of iron possesses all these properties. It is perfectly soluble. Chlorine is an
abundant and important element of the principal fluids of the body. It is thera-
peutically compatible with most of the medicinal substances used in the treat-
ment of phthisis, such as quinine, morphia, chloric ether, hydrochloric acid,
phosphoric acid, chlorate of potass, etc. I have tested experimentally the ma-
jority of the preparations of iron, and find none so generally to answer as the
perchloride. I have found it occasionally to cause nausea, but this soon ceased
on lessening the dose. I have used the pyro-phosphate of iron in several cases
where the perchloride was objected to. Its effects have satisfied me that it is in
many respects equally as useful as the perchloride. It appears to possess neu-
rotonic properties, and to act very similarly to a combination of perchloride of
iron with phosphoric acid. The syrup of superphosphate of iron introduced by
Dr. Routh is also a useful preparation. Secondly, with reference to the dose.
I have reason to believe that the disuse into which the preparations of iron have
fallen in the treatment of consumption is mainly referable to the custom of pre-
scribing it in large doses. Disorder of the organs of digestion, also headache,
and other symptoms of either hypersemia or of the presence of an unnecessary
substance in the blood, are the consequences of its excessive use.

"In healthy blood the quantitative correlation of its elements is pretty con-
stant, but in the cachexia of tuberculosis this condition is disordered, and the
object of our treatment should be the restoration of the normal relation of its
elements.

" Thus, in using iron as a curative agent, the quantity should be sufficient,
and only siifficient, to supply the waste of that element shown by the diminished
numbers of red corpuscles. Any excess of this quantity tends to embarrass the
system by the presence of an unnecessary element. It is obvious that the dose
must vary according to the requirements of each case. I am convinced, by
experience, that the dose generally given is far too large. When the state of
ansemia is strongly pronounced, the dose of a ten per cent, tincture of perchlo-
ride of iron may be fifteen minims three times a day, but it will soon be, found
necessary to reduce it considerably. In a large number of cases, from three
to five drops twice or three times a day will be found sufficient to meet the
requirements of the system. In these small doses the remedy maybe used for a
long time. I have in many instances exhibited it continuously for more than
twelve months without the occurrence of any of the symptoms mentioned as
interfering with its use.

"In order to derive the full benefit from the use of iron in phthisis it must be
continued for a long time ; for it is not only necessary to establish a healthy
sanguification, but also to maintain it. The condition of cachexia attending
tuberculosis tends to lower the standard of the blood, and this tendency is con-
stant. If by any means a healthy condition of the blood be produced, it cannot
long be maintained without the continued use of hsemagenetic agents ; hence
the necessity for the exhibition of iron over a long period. I would dwell upon
this point as one of paramount importance. It is in the continuous use of it

1862.]

Medical Pathology and Therapeutics.

223

over a long time — one, two, three, any number of years — as long as not only the
condition of, but the tendency to, tuberculosis exigts, that its value as a remedy
is manifested.

"The improvement in the state of health which takes place during the exhi-
bition of perchloride of iron shows itself in the increase of bodily vigour and
capability of undergoing fatigue, the improvement of the appetite, and the abate-
ment of the well-known symptoms of impaired digestion, such as flatulency, heart-
burn, acidity of the stomach; in the diminution or cessation of night perspiration,
and of the tendency to perspire on slight exertion ; in the abatement in the
severity of the cough ; in the decrease in the quantity of expectoration, and in
the less frequent return or complete absence of haemoptysis,

" "While endeavouring to show the great importance of iron in the treatment
of consumption, I wish to guard against the possibility of being misunderstood.
My desire is merely to direct attention to its claims as a powerful agent in the
treatment of that disease, to point out the proper mode of its administration,
and to assign to it its place in the materia medica for consumption. I do not
propose the use of iron as a substitute for cod-liver oil. Each of these agents
has a distinct function to perform in aiding nutrition and promoting a healthy
sanguification. In a large number of cases both are necessary, each acting a
part peculiar to itself, yet complementary to the other."

20. Chlorate of Potassa in Phthisis. — Dr. R. P. Cotton has experimented
with the chlorate of potassa on 25 patients in the Hospital for Consumption,
Brompton, and his results are by no means favourable.

" The generally acknowledged tonic, antiseptic and upholding influences of
the chlorate of potassa, have caused," he observes, "this agent to be rather
extensively tried in consumptive cases. The results, however, have been very
variously stated ; but, in a recent number of the Dublin Quarterly Medical
Journal, a physician of Belfast has unhesitatingly brought it forward as a
specific for pulmonary tuberculosis, at least in the first and second stages of
that disease.

" Of the twenty-five cases for which I prescribed it, fifteen were males and ten
females. Eight were in the first stage, eight in the second, and nine in the third
stage of phthisis. They varied in age : one had reached fifty ; but the rest were
from twenty to thirty years. Notes were regularly taken by Mr. Harington,
resident clinical assistant.

" Of the entire number, five improved considerably, four improved a little, and
sixteen seemed to derive no advantage. Of the latter number, four, at least,
may be said to have been more or less benefited when the chlorate was ex-
changed for some other tonic.

" The period during which it was administered varied in different cases. In
this, as in the preceding experiments, my habit has been to continue the same
treatment for at least three weeks. If, at the expiration of that time, very little
or no progress has been made, I have tried something else ; but whenever there
has been encouragement to proceed, I have done so. My notes record that the
chlorate of potassa was taken in five cases, for periods varying from six to ten
weeks ; the average being four weeks. The dose was ten or twelve grains three
times a day.

" In twelve cases cod-liver oil was occasionally, but not quite regularly, taken
at the same time. It would, of course, have i3een more satisfactory had the
chlorate in every instance been administered alone ; but many patients on enter-
ing the hospital are already so practically acquainted with the good eSfects of
the oil, that it would be cruel to deprive them of its use, whilst in such cases
the attempt to do so would in all probability only prove abortive, for I have
many times discovered that patients for whom I have not prescribed cod-liver
oil have very significantly testified to its usefulness by taking it clandestinely.
In analyzing those cases in which the oil had been taken, I find that six belong
to the list of nine more or less improved patients.

"Nine increased in weight whilst taking the chlorate, seven lost weight, and
nine underwent no change. Of the nine who gained in weight, six belong to
the number who had also taken, more or less, the cod-liver oil.

224

Progress of the Medical Sciences.

[July

"Of the improved cases, three were very decided, the patients having ex-
pressed themselves as feeling better than they had done for many months ; two
of these, however, belong to the class who had taken the oil. It was generally
observed that those patients in whom there was any perceptible improvement
were of broken down and cachectic constitution; indeed, just in that condition
in which, without regard to their being phthisical, the chlorate of potassa might
very hopefully have been prescribed.

" The preceding facts, taken in connection with the very potent influences of
improved sanitary and dietetic arrangements to which all the patients were
subjected on entering the hospital, would seem to justify the following conclu-
sions : —

"1. That chlorate of potassa has no specific action upon consumption.

" 2, That its usefulness, even as an auxiliary in the general treatment of
phthisis, is very questionable, and is probably limited to that cachectic class of
cases in which it and allied remedies are so often serviceable." — Med. Times
and Gazette, May 24, 1862.

[These conclusions are confirmatory of those of Dr. Flint, whose interesting
report will be found in our No. for October, 1861, p. 321.]

21. Delirium Tremens ti^eated hy Large Doses of Digitalis. — In our No.
for January last we quoted four cases of delirium tremens successfully treated
by large doses of digitalis. Another case has been related [Med. Times and
Ga%., April 26, 1862), which occurred at the Eadcliffe Infirmary, Oxford, under
the care of Mr. Hester. "A drayman, aged 28, of very powerful frame, was
admitted for a contused wound in the occiput, caused by falling backwards
whilst intoxicated. The hemorrhage, which had been very free, was checked
by the application of a little pressure ; and being put to bed he soon fell asleep.
Next day he appeared to be suffering from the effects of his debauch, and, as
he craved very much for a drop of beer, a pint of ale was allowed, which made
him feel more comfortable ; but in the evening he was seized with a violent fit
of epileptiform convulsion, which lasted for about ten minutes. Another half
pint of ale was given to him. with the same result as before ; and during the
night he had two slighter fits of the same character.

On the second day he complained of pain in the head, and, his bowels being
confined, a good dose of calomel and jalap was administered, to be followed by
sulphate of magnesia every four hours, and cold applied to the head. His bowels
were freely opened, and he was quiet throughout the day and the following night.

" On the third day he became restless and fidgety, and was with difficulty kept
in bed,- being frightened by some imaginary object which he said constantly
pursued him. In the night he got out of bed, and had to be carried back by
force, in spite of his most violent efforts to the contrary. A strait-waistcoat
was applied, and half an ounce of tincture of digitalis given in water. He soon
became quiet, muttering a sentence in low voice now and then, and continued
so through the night, but did not get any sleep. Next day he was restless, and
towards night became again very violent. A second dose of the digitalis was
administered, and in a few minutes he fell asleep, and slept through the night
and the greater part of the next day. After this he became very quiet and
comfortable, and has progressed up to the present time very satisfactorily, the
wound having nearly healed."

Dr. MoRRELL Mackenzie has tried the tincture of digitalis in three cases of
delirium tremens [Lancet, March 8, 1862) in the doses recommended by Dr. Jones,
of Jersey, and in two of these cases death occurred, and in the other the digitalis
had to be abandoned, and recourse had to stimulants and opiuni, under which

the patient recovered. " One of these patients, W. P , aged twenty-eight, a

potman, and an habitual dram-drinker, was admitted into the London Hospital,
under the care of Dr. Fraser, at seven o'clock in the evening of the 6th of July,
1861. Though he was fearful and highly tremulous, his case did not .appear
unusually severe. On auscultation, there were no signs of cardiac disease, and
half an ounce of the tincture of digitalis was accordingly prescribed. A nutri-
tious diet was ordered, but no stimulants were allowed. An hour later the pulse,
which was previously at 84, was reduced to 60 ; it was full and regular. At ten

1862.]

Medical Pathology and Therapeutics.

225

o'clock the dose was repeated, and the patient passed a quiet, though sleepless,
night. In the morning another half ounce was given, and in the afternoon the
dose was again repeated. On both occasions, about half an hour after taking
the medicine, vomiting supervened. There was no increase in the renal secre-
tion. The patient did not appear much distressed by the sickness, and in the
afternoon he had a steady pulse of 68. During the day he became very restless,
and, instead of being timid and subdued, was now fierce atid fearless, requiring
powerful restraint. In the evening he was still more violent, and at nine o'clock
the digitalis was again repeated, but this time only two drachms were given.
Between ten and eleven, being now even more excited, it was determined to
discontinue the digitalis and try opium ; but before the latter drug could be
administered, after a short but violent struggle with his attendants, which at first
appeared voluntary, but afterwards convulsive, the patient suddenly expired.

" The following extract from the account of the post-mortem examination
shows the condition of the heart after death, and perhaps some relation between
the therapeutics and the pathology : ' Little fluid in the pericardium, in which
the heart lay like a flaccid empty bag. To the touch, before removal, the cavities
of the heart and large vessels seemed almost empty. On cutting across the
great vessels, only a small quantity of dark fluid blood escaped : the whole heart
felt flaccid, and its cavities did not contain half an ounce of blood.' I may men-
tion that there was no appearance of disease in the brain or membranes, except
that the dura mater was slightly adherent to the skull in the parietal and occipital
regions. There were a few drachms of serous fluid in the lateral ventricles.

" In the case of the next patient, who died after the administration of half an
ounce of the tincture of digitalis (which was given to him by a practitioner
shortly before he was brought to the hospital), the man was admitted in a semi-
comatose condition, from which he never roused, and unfortunately his friends
objected to an autopsy.

" The third case was that of H. N , aged forty-five, a butcher, admitted

under the care of Dr. Frazer, on the 14th October, 1861, with the usual symp-
toms of delirium tremens; 'the hands and tongue were tremulous, and, though
slightly excited, he was quite sensible.' The opiate treatment was adopted, but,
no improvement taking place, it was determined to try digitalis. Within eleven
hours the patient took an ounce and a half of the tincture of digitalis, in three
half-ounce doses. Though the frequency of the pulse was diminished, the nerv-
ous symptoms were aggravated ; and, from the report of Mr. Fred. Carter, it
appears that ' an hour after taking the draught (the third dose) the patient be-
came very troublesome and violent — so much so that he was removed to the
attic and placed in a strait-jacket.' Opium in large doses was now prescribed,
and the patient was put under chloroform, in order that the system might be
more readily affected by the narcotic. On the 29th October, after taking five
drachms of the tincture of opium in nineteen hours, he slept for some hours,
and awoke quite collected. The effects of the digitalis were very similar to
those produced in the potman who died, for in both the timidity of delirium
tremens gave way to the fury of acute mania.

" With regard to the cases recently reported in the medical journals, it appears
from Dr. Harrison's letter in the Lancet of Feb. 15, that before any digitalis
was administered the patient was ' quieter,' an admission which somewhat de-
tracts from the supposed curative eff'ects of the digitalis ; and in the case reported
by Dr. Duchesne, it is stated that ' it was a primary attack occurring in a young
man of tolerably regular habits' — circumstances so favourable in themselves,
that almost any remedy might be expected to prove especially useful. It is to
be observed, too, that in both the cases recently placed before the profession
large doses of opium had been previously administered ; and it is not difficult
to suppose that an abnormal condition of the nervous system should have
delayed the absorption of the narcotic, which, afterwards taking effect, pro-
duced the curative results ascribed to the digitalis.

"In conclusion, I may remark that 'the usual hospital treatment energetically
pursued,' consisting of stimulants, nourishing food, and opiates, rarely fails ; and
that it is seldom that a patient dies in this hospital from delirium tremens, unless
his case is complicated with serious traumatic injury."
No. LXXXYIL— -July 1862. 15

226

Progress of the Medical Sciences.

[July

22. Treatment of Pleurisy. — M. Trousseau rarely employs bloodletting in
the treatment of pleurisy ; he scarcely ever cups even at the commencement of
the disease. As an antiphlogistic, he prefers calomel in minute doses, adminis-
tered, according to the method of Low, aconite and digitalis. A favourite mode
of treatment in these circumstances is the following : calomel, a grain and a
half, powdered sugar, a drachm and a half. To be carefully mixed and divided
into twenty powders, of which one is to be taken every hour or every two hours.
Tincture of aconite, and tincture of digitalis, of each fifteen drops ; ordinary
julep, five ounces. A tablespoonful to be taken every two hours. The pleuritic
pain may be relieved by the application of a compress soaked in chloroform, or
in a watery solution of opium. The part having been rubbed for five minutes
with the latter preparation, a moist rag is to be placed over it and covered with
a piece of oiled silk.

When pleurisy is complicated with eff'usion, M. Trousseau has never recourse,
in order to favour the absorption of the serous fluid, to blisters, so generally
used in this state. Blisters, and especially large blisters, present several dis-
advantages ; they cause great suff'ering, and are often the cause of ecthyma,
abscesses, boils, carbuncles, erysipelas, and other severe accidents. Not long
ago, there was in the Hotel Dieu a patient who had been treated outside on
account of pleurisy, and who, as the result of a blister, presented two abscesses
of the thoracic parietes, so situated that they at first appeared to communicate
with the interior of the chest, or to be symptomatic of caries of a rib. They
had, however, been produced by the application of a blister, and on being dressed
in the usual way soon healed.

M. Trousseau's treatment of effusion varies according to its importance. If
the amount is inconsiderable, he confines himself to the administration of digi-
talis in doses of ten or fifteen drops, of diuretic drinks, quiet, and a light diet.
If the effusion is consideifable and the pleurisy simple, he evacuates the fluid by
means of thoracentesis. M. Trousseau does not allow himself, under these cir-
cumstances, to be guided by the degree of oppression. He has actually seen
two women, affected with enormous pleuritic effusions, die suddenly, without
having experienced the least dyspnoea. One of these patients was a nurse, at
the twelfth day of pleurisy ; she died while sleeping, and her countenance ex-
pressed the most perfect calm. M. Trousseau is inclined to share the opinion
of Aran, who recommended that the operation should be practised as soon as
the effusion had reached the fourth rib ; in fact, in these circumstances he has
never seen a bad result follow. However, he seldom operates until the fluid has
reached the level of the clavicle.

The operation is very simple ; the puncture is made in the fourth or fifth
intercostal space. If there is no other means at hand to prevent the introduc-
tion of air into the pleura, the wide end of the canula is plunged into the fluid
which is flowing out. and this latter is itself an obstacle to the entrance of air.
Thus practised, thoracentesis has always excellent results when the effusion is
on the left side, that is to say, when the pleurisy is simple ; for Aran found, by
clinical observations, that, ninety-five times in a hundred, pleurisy of the right
side is secondary, being connected with tubercular disease of the lungs, while
pleurisy of the left side is generally primary.

In the case of tubercular pleurisy with effusion, thoracentesis maybe resorted
to as a palliative, although necessarily with little chance of success. Topical
applications are, however, often useful, particularly the repeated application of
ioduretted preparations, and especially of the alcoholic tincture of iodine. — Ed.
Med. Journ., April, 1862, from Journal de M^d. et de Chirurg. Prat., March,
1862.

23. Pneumonia in Infants. — M. Barthez, who is well known to the medical
world by his valuable work on Diseases of Children, which he undertook in
common with the late M. Rilliet, of Geneva, has lately given us an interesting
account of his most recent experience on pneumonia in infants. From 1854 to
1861 he has in hospital practice observed 212 cases of genuine pneumonia in
infants, and only lost two patients, both of which were affected with bilateral
pneumonia. One-half of the children suffering from inflammation of the lungs

1862.] Medical Pathology and Therapeutics.

221

who came under M. Barthez's care were subjected to no treatment whatever;
in a number of others the treatment was confined to an occasional purgative,
emetic, or bath ; and only in one-sixth of the cas^s active remedial measures
were resorted to. Besides these, M. Barthez has treated a large number of
similar cases in private practice with similar results. He therefore concludes
that genuine and non-complicated pneumonia in children is, at least as far as
Paris is concerned, a mild disease, whatever may be the seat and extent of the
inflammation, the seasons, and the years, and whether the medication employed
be active, insignificant, or absolutely none. Double pneumonia is, however,
more dangerous, as two patients died out of thirteen affected by it. The age of
the patients was between two and fifteen years. Pneumonia complicated with
other diseases, such as typhoid fever, tuberculosis, etc., is of altogether a differ-
ent character.

Concerning the duration of the several stages of the disease, M. Barthez
remarked that if no treatment was pursued, resolution commenced between the
sixth and eighth day from the commencement of the disease, and more especially
on the seventh day ; in some cases, however, it began as early as the fourth or
fifth day, or was retarded till after the eighth.

A mild treatment produced no change in this respect ; and the disease being
essentially benignant, M. Barthez rejects the antiphlogistic treatment altogether,
so much the more as he has seen that several children who were treated with
bloodletting, etc., made a bad recovery, and for a long time remained pale and
emaciated. In only four patients he found it necessary to have recourse to
repeated phlebotomies ; and in these instances resolution commenced on the
fifth, sixth, seventh, and tenth days. If resolution has once begun, there is
soon an end of the disease, viz., between two and six days, it being only seldom
protracted from seven to ten days. This natural duration of the stage of de-
crease is not sensibly altered by any treatment : but if the latter is very active,
the patient does not find any benefit from it. Pneumonia in infants generally
terminates in ten days or at most within a fortnight, if left to itself ; but if severe
antiphlogistic measures are resorted to, the disease may be protracted. In
double pneumonia a fortnight is generally the shortest term of the disease. The
recovery is always most rapid in those children who have had no, or scarcely
any medicine ; these almost invariably get well within a fortnight, while in those
who have been actively treated convalescence often lasts from fifteen to thirty
days. As regards the seat of the affection, resolution is quickest if the middle
part of the lung is affected ; inflammation of the top and the base of the lungs
has much the same duration. The general conclusion to be drawn from all the
facts mentioned is, that careful attention should be given to hygiene, and that
as little medicine should be prescribed as possible. Occasional emetics, purga-
tives, warm baths, or bloodletting are in certain cases useful for relieving the
pain in the side and the oppression on the chest. — Med. Times and Gazette,
May 10, 1862.

24. Treatment of Cancrum Oris. — Dr. Alexander Keiller read before the
Medico-Chirurgical Society of Edinburgh (5 March, 1862) a highly interesting
paper on the nature, causes, and treatment of cancrum oris. With regard to
the character and value of the treatment which he considers ought to be had
recourse to in this disease, he remarks : —

"In the first or mildest form of stomatitis, viz., the simple foUicular variety,
which appears either in the form of aphthce or superficial idceratiojis, little more
is required than attention to the stomach and bowels ; for, by simply correcting
any intestinal or gastric derangement, the follicular disease generally disappears.
If local applications are necessary, borate of soda in solution, or solution of
nitrate of silver (four or five grains to the ounce), will generally do all that is
required.

"In the second or idcerative form (which is of frequent occurrence, and if
neglected, may prove in some cases serious), a tonic treatment is to be enjoined,
and, above all, the administration of chlorate of potash, which Dr. West and
others have called a specific in this affection. Dr. West gives it in doses smaller
than those in which I usually prescribe it. I give ten grains every two or three

228

Progress of the Medical Sciences. [July

hours, and, when combined with the local application of Condy's solution every
second day, and the free administration of wine and iron, I have seldom required
to do anything else, except of course to remove any loose teeth or alveolar exfo-
liation acting as sources of irritation.

"In the third and dangerous form, to which I have more specially been refer-
ring, viz., the gangrenous form of stomatitis, the treatment is, like that of the
others, twofold, local and constitutional ; the local being here, however, much
more severe, amounting to absolute destruction or removal of the morbid tissues
by cauterization ; the general or constitutional consisting in whatever will tend
to build up and invigorate the system, such as quinine or other tonics, full diet
with wine, together with ten-grain doses of chlorate of potass often repe?ited.

" The great object to be kept in view is the perfect arrestment or total removal
of the gangrenous action ; for, if we trust to the occurrence of a spontaneous cure,
or allow the sloughing process to progress unchecked, which we are too apt to
do on first seeing a case of this kind, we shall soon find it too late to have recourse
to suitable treatment, the local death having stealthily extended beyond the
bounds of arrestment, when even the most energetic measures will in all proba-
bility prove unavailing.

"There can be no doubt as to the propriety of at once attacking locally the
local manifestation of the disease, whatever its real essence may be, for here the
sooner we destroy, the less will be the ultimate destruction ; and although it
may, to those especially, who may not have witnessed cases of the kind, seem a
cruel and uncalled-for procedure to cauterize "the apparently slightly-affected
cheek of a perhaps not unhealthy-looking child — a child whose appetite may be
little afiected, or whose pulse or expression may not indicate any immediate
danger, although to others it may seem harsh, and may be unpleasant to our-
selves, still the duty ought to be in all suitable cases timeously and properly
done.

"Although it is now impossible to say what would have been the result of
early and thorough cauterization, in the fatal case which recently occurred in
the Children's Hospital (and of which a correctly coloured wax model is now
exhibited), there can be no doubt that the serious nature of the case had been
overlooked until the disease had made considerable progress, when the local
applications first used were neither sufficiently corrective to change, nor suffi-
ciently corrosive to destroy, the sloughy actiou in the parts involved.

" I believe that the issue would not have been different had the hydrochloric
or other acid been applied on admission ; and my reason for first applying the
^erchloride of iron, and also Condy's solution, was to see if either of these local
remedies would have any beneficial effect along with the general tonic treatment
which was at the same time studiously adopted. The mortification having in
this case involved the entire thickness of the cheek, there was little hope of
checking it after the admission of the patient.

"Be that as it may, from what I have seen and known of cancrum oris, I would
rather, in any future case, be inclined to overdo than underdo — rather run the
risk of disfiguring too much than of destroying too little ; for cauterization, if
Uot effectual, is worse than letting alone ; and now that we can avail ourselves
of the aid of chloroform, there need be no hesitation in at once setting about
this to my mind essential matter. Without chloroform, it is a difficult as well as
a painful task to apply caustic or other substance efficiently to the interior of a
child's mouth, and especially 50 in the diseased condition we are now consider-
ipg ; for here the difficulty of seeing the internal sloughy surface to which the
escharotic ought to be applied, is very much increased by the peculiar tense and
tumid state of the affected cheek, which, even under chloroform, materially inter-
feres with our getting at the exact part which we may desire to cauterize. In
fact, this swollen an,d tense condition of the affected cheek, although an early
and valuable external characteristic of the condition of the internal surface, is
generally the cause of our not diagnosing and treating cases at the proper time,
that is, before the sloughing process has extended outwards beyond the mucous
or inner texture of the cheek, in which the disease usually commences, and to
which, therefore, our local remedies ought to be early applied.

"With chloroform this difficulty is very much overcome, as was found in one

1862.]

Medical Pathology and Therapeutics.

229

of the cases I have cited, and in which there can be little doubt as to the success
of the local treatment which was had recourse to. The arrest of the disease
was very apparent in that case, and the advantage o'f chloroform was undoubted,
as it enabled me not only to displace the swollen cheek, but to expose its affected
surface and the adjoining gums, and thereby allowed me to see what required to
be done, and thus greatly facilitated the doing of it.

''In the case referred to, I used nitric acid, and, as stated in the report, found
one application sufficient. The cheek was forcibly turned out, the tongue and
adjoining parts were protected from contact with the acid, which, in the absence
of a glass rod, was applied by means of a test-tube. Some apply it by means of
lint or tow attached to a probe or quill, but the glass rod, or, better still, a glass
brush (such as I' now exhibit), answers every purpose required.

"In every case care must be taken to see that under the yellow slough or
eschar left by the first cauterization, there do not lurk unaffected sloughy por-
tions ; if so, the acid should be reapplied on the following day, and the mouth
should be occasionally syringed with solution of chloride of lime, in order to
remove the putrid discharges and get rid of the gangrenous emanations which,
so long as the dead and dying tissues are left exposed or unaltered, must neces-
sarily prove highly deleterious, if they be not the more immediate and direct
cause of death. The danger arising from the presence of decomposing matter
cannot be too constantly borne in mind in dealing with cases of true cancrum
oris ; for, whatever be the exact pathological nature of the structural change —
whether simply the result of an inflammatory exudation into tissues unusually
prone to serous infiltration and capillary death, or consequent on contamination
of the circulating fluids (a general blood-poisoned condition leading to a special
disorganization in the affected parts), there is to my mind no great difiiculty in
accounting for the marked fatality attending the disease when allowed an un-
checked course ; indeed its fatality seems explicable enough, without looking for
any cause of death beyond or apart from the mouth itself, for there we find a
mass of gangrene which, having lost the inherent power as well as the inherent
character of living tissue, is not only incapable of self-regeneration, but is most
unlikely to be spontaneously separated or removed by absorption. It is, I con-
sider, by no means improbable that death ensues in such cases not so much from
any previous diseased condition or contamination of the blood, as from the con-
tinued and unavoidable inhalation of the poisonous exhalations arising from
the gangrenous degeneration within the mouth, which must necessarily be a
much more active, as it is doubtless a much more direct medium of blood-con-
tamination than mere local absorption, which latter agency, together with the
actual deglutition of the foul discharges from the affected structures, materially
tends to destroy life.

"It appears to me, that children dying from unchecked cancrum oris are in a
great measure poisoned by the inhalation of the deleterious gases arising from
their own oral textures in a more or less complete state of putrefaction ; and
that this view of the cause of the extreme fatality of the disease not only explains
the immediate cause of death, but points to the necessity for adopting the line
of treatment I have so strongly recommended, in order to prevent the air inhaled
from being thus directly poisoned.

"It may, I think, be safely affirmed, that so long as simple ulcerative action
exists, this mode of death need not be feared ; but that, whenever gangrene /rom
degeneration takes place within the mouth, fatal consequences may accrue ; for
if foul air, under any circumstances, be poisonous — if the emanations given off
from putrid animal matters be deleterious in proportion to the degree of con-
centration in which they are inhaled, what I have now advanced must, I appre-
hend, be correct. This view of the pathology of the disease, moreover, accounts
not only for the efficiency of such substances as chlorate of potass in the milder
and more curable form of stomatitis, but justifies us in preferring active and
well-timed local, to less powerful or merely general treatment in gangrenous
stomatitis, in which the air within the mouth is so polluted as to render the
atmosphere, not only immediately around the unfortunate patient but throughout
the entire apartment, in the highest degree offensive.

"If this be true (and those who have ever visited a well-marked case of can-

230

Progress of the Medical Sciences.

[July

crum oris can voucli for tlie fact), the conclusion is obvious, and may be thus
shortly put. If it be dangerous to allow a foul drain or open cesspool to pollute
the air which enters the lungs, the sooner the nuisance is either removed or
covered over the better. And this is exactly what cauterization accomplishes
in the case of cancrum oris ; for, if it have not the effect of immediately disinte-
grating and removing the entire putrid mass, it either so far changes its charac-
ter, or, at least, for the time being so covers or crusts over the gangrenous
degeneration, as to check or altogether prevent the farther escape of those
offensive and most deleterious exhalations, which would otherwise freely mix
with, and therebv render poisonous, what may be emphatically called the 'breath
of life.'"— ^;cZ. Med.-Journ., April, 1862.

25. Patliology and Treatment of Jaundice. — Dr. George Harley read a
paper on this subject (May 13, 1862) before the Eoyal Medical and Chirurgical
Society.

It is universally admitted that the facility of the diagnosis of jaundice is only
equalled by the obscurity of its pathology and the uncertainty of its treatment.
In this communication, therefore, the author set about unravelling the nature
of the various morbid conditions which give rise to it; and pointed out how,
notwithstanding the seeming discord, they could all appropriately come under
the two common heads of "jaundice from suppression of the biliary function."
and "jaundice from the reabsorption of the secreted but retained bile." More-
over, I)r. Harley showed that the pathology of jaundice resulting from suppres-
sion is totally different from that arising from obstruction : and, consequently,
that a line of treatment which would be appropriate and beneficial in the one
form, would be detrimental, if not actually hazardous, in the other. Fortunately,
however, the author pointed out a new method of distinguishing the two forms
of the disease when all the ordinary means of symptomatic and physical diagnosis
prove unavailing. The method consists in analyzing the urine, which, he finds,
contains different morbid products according to the particular form of the dis-
ease. Thus, for example, in jaundice from suppression the urine contains only
those biliary ingredients which exist preformed in the blood. In jaundice from
obstruction, on the other hand, the urine contains, in addition to these, the
materials generated in the liver itself, and which have been reabsorbed into the
circulation from the distended gall-bladder and ducts. A simple mode of distin-
guishing the two conditions is, to add to about two drachms of urine half a
drachm of strong sulphuric acid, and a fragment of loaf sugar the size of a pea.
If at the line of contact of the two liquids a scarlet or purple colour is produced,
it proves that the acids of the bile are present, and the case may consequently
be put down as one of jaundice from obstruction. On the other hand, if no
bile-acid reaction, but merely a browning of the sugar, be observed, the case is
in all probability one of suppression. Dr. Harley pointed out, however, that
care must be taken not to confound the two cases; as jaundice from obstruc-
tion, especially the severe form, often merges into jaundice from suppression.
The author also confirmed Frerich's statement regarding the presence of tyrosine
and leucine in the urine of acute atrophy of the liver ; and further stated that
he had also found these substances in the urine of chronic atrophy, so that their
presence might aid in the diagnosis of the latter as well as of the former condi-
tion of the hepatic organ. Several cases were cited illustrating the value of the
different methods of diagnosis; and the author concluded by pointing out the
class of cases in which mercury and other remedies were likely to be beneficial,
and where they were likely to do injury. He specially recommended the em-
ployment of benzoic acid in jaundice from suppression, and inspissated bile in
that arising from obstruction, in which latter class the patient frequently dies
from slow starvation, in consequence of the absence of bile in the digestive
process causing imperfect assimilation of the food to take place. Dr. Harley
also called special attention to the fact that bile, as now employed, more, fre-
quently does harm than good ; for, when given along with the food, instead of
aiding the digestive process, it actually retards it by interfering with the action
of the gastric juice. If, on the other hand, bile be administered, as the author
proposes, at the end of stomachal digestion, it acts (as in the healthy organism)

1862.]

Medical Pathology and Therapeutics.

231

on the chyme, and renders it fit for absorption. In order still further to insure
this desirable object, Dr. Harley has had bile specially prepared and put up
into capsules, which are not readily acted on by the gastric juice, but which, on
being dissolved in the duodenum, allow the bile to come in contact with the food
at the proper moment, and thereby enable the physician to imitate nature, and
supply an important element to the system. The communication was well illus-
trated with preparations and drawings. — Jled. Times and Gaz., June 7, 1862.

26. Treatment of Dysentery. — In the acute form, and in the inflammatory
stage, bloodletting, general and local, remarks Dr. S.maet [ClimatoL, etc., of
Hong-Kong), and the warm bath, are always the earliest means to be used.
Everything should be done with a view to diminish the inflammatory impulse, to
keep the muscular coat of the bowel at rest, and to determine to the surface, as
long as the excretion is of mucus and blood, and, d fortiori, when it is of serum,
blood-corpuscles, and lymph-flakes. Purgatives of any kind, especially calomel,
which excites the discharge of bile into an already inflamed canal, can only have
an injurious eflFect. Astringents, which tend to check the exosmotic action by
which the inflamed capillaries are relieving themselves, are pernicious. Ipeca-
cuan possesses of all known remedies the most relaxant power on mucous tissues,
causing a kind of internal diaphoresis and checking the peristaltic action of the
lower intestines, by nauseating and thus reversing that of the upper part of the
canal, and by producing vomiting, by which the secretions poured in by the
lower and the upper mucous glands are prevented passing through the large
intestine. Opium, which calms the nervous excitement, deadens the pain and
assists in moderating peristaltic action, is also invaluable. In this consists the
merit of the treatment proposed by Surgeon Docker, of the Eoyal army, from
his practice in the Mauritius, of giving large doses of ipecacuan combined with
laudanum. In my practice I have found the most satisfactory results from this
treatment, preceded by venesection and the warm bath. The recumbent jDosture
and epithems to the abdomen, with absolute diet of rice or barley water, are
most important adjuncts. When the tenesmus is lessened, and the passage of
bile and feces shows the cessation of ileo-colic obstruction, a laxative of castor
oil, with laudanum or oil of turpentine, will be useful ; but after the second or
third fecal stool, further action should be checked by opiates, administered by
mouth, and in starch injection. As the symptoms moderate, the doses of ipeca-
cuan are to be gradually diminished ; and, at last, when bloody mucus has giyen
way to opacjue mucoid or muco-purulent discharges, some mild alterative, such
as hydrar. cum creta, may be combined with the ipecacuanha.

This mode of treatment, as far as I have seen, cures more in the first stage,
by resolution, than any other; but, even with it, absolute success must not be
expected, as some cases will run to a fatal termination in the first stage, and
others will progress to the second stage, with dense infiltration of the submucous
tissue. This is known to have occurred when the pyrexia having abated, there
remains a minor degree of tenesmus and tormina, with tenderness. <iccompanied
by an altered state of the evacuations. Then, the modified treatment, by ipeca-
cuan with alteratives, epispastics, and sometimes leeching over the tender points,
and anodyne enemata, especially about midnight, is still most to be relied on.
If breach of mucous surface has occurred, as indicated by renewal of mucus
streaked with blood, and pultaceous or curded matter in the stools, the use of
the vegetable tonics and astringents, as cinchona, quinia, and calomba, with
occasional alterative laxatives, is to be had recourse to, and a broth, farinaceous
diet, with a little port wine, may be allowed. If the symptoms be obstinate, the
alternation of the mineral astringents, especially if there be passive hemorrhage,
will be advisable. The terebinthinates will often be of great service in this stage ;
but should the urinary bladder partake of irritability they must be suspended.
Unless the patient can be brought to feel that all injudicious ingesta are most
detrimental to the diseased alimentary canal, any mode of treatment will be very
unsatisfactory. — Trans. Epidemiolog. Soc. of London, May, 1861.

27. Suhnitrate of Bismuth in Diarrhoea and Chronic Dysentery. — Subnitrate
of bismuth is considered in the present day one of the best remedies in cases of

232 Progress or the Medical Sciences. [July

diarrlioea, and is employed with great advantage in the treatment of chronic dysen-
tery. Under its influence the ulcerations cicatrize, the fetid gases are destroyed,
and the excrements become black and lose their putrid character. But as the
medicine requires to be taken in large doses, in order that it may exert a bene-
licial influence, some patients soon become disgusted with it, in spite of its in-
sipidity. Dr. Gaubert announces that he has found cream a very convenient
recipient for its administration, especially in the case of young lymphatic subjects,
who generally require tonics, and in whom the sensibility is often exaggerated.
This preparation, due to Dr. Quesneville, has the advantage of presenting the
subnitrate of bismuth in the form of a thick cream, which, on the addition of
water, forms a milky fluid, without granular residue ; and it will be readily com-
prehended that this state of minute division is highly favourable to its diffusion
throughout the digestive canal, and consequently to the rapid obtaining of its
therapeutic effects; so that smaller doses than ordinary are sufficient. — Gazette
Hebdom., 28 Feb. 1862, from Gaz. M6d. de VAlgerie, 25 Dec. 1861.

28. Saccharine Treatment of Diabetes Mellitus. By John Hughes, M. D. —
The saccharine plan of treating diabetes originated, I believe, in France, and so
far back as 1845. Bouchardat gave saccharine fruits in diabetes, and bread
made from gluten. Andral and Fiorry tried a similar treatment, with some
success. And the practice has been recently adopted in England, by Dr. Budd,
of Bristol, who has published some cases (two, I think) in which he says the
most marked amendment followed the use of sugar. Others have also recorded
cases ; but they do not exhibit so favourable a result as those of Dr. Budd. It
would appear, however, that some practitioners who tried this plan have found
it beneficial. Their patients grew fat upon it ; and even this effect, in a disease
where wasting is so prominent a symptom, is a very desirable result. They say,
besides, that the practice is not an irrational one ; for Bernard has shown that
sugar taken into the stomach, in its passage through the liver, is converted into
an emulsive substance, which tends to fatten patients ; and he has also proved
experimentally, and Andral and others practically, that sugar is secreted and
found in the circulation in diabetes, whether the individual be fed upon nitro-
genous ,or amylaceous substances : consequently our old-established plan of
dietetics in this disease, with all its restrictions, is useless.

Dr. Budd, one of its earliest advocates in England, says he gives sugar in
diabetes on the principle of supplying to the system the particular element
which is running to waste, and the loss of which appears to be the principal
cause of the damage sustained by the constitution as the disease advances. On
all these grounds, then, it has been considered that the saccharine treatment of
diabetes is worthy of a trial.

Amongst the many theories propounded concerning this intractable disease,
modern researches incline to the opinion that the liver is the organ in fault — an
idea long since entertained by Dr. Front. Experiments by Bernard and Favey
tend to show that there is always present in the liver, located in the hepatic
cells in considerable abundance, a substance which one calls the "glucogenic
matter" of the liver, the other "hepatine;" that this substance is, with great
facility, by a process allied to fermentation, converted into sugar ; but that it
seems to have the power, whilst located in the tissues of the living and healthy
liver, to resist the transformation. In certain unnatural conditions, however, as
well as after death, this power is at an end, and the blood becomes surcharged
with saccharine principle.

If this be true, it would appear that the diabetic condition depends upon some
functional derangement of the liver, which converts alimentary substances into
this glucogenic matter in greater abundance than natural, and allows it to mix
with the blood in large quantity, when it immediately becomes converted into
sugar, and as such passes off with the urine.

I am not sure, even assuming all this to be correct, whether we are in a better
position to decide upon the exact nature of this disease. Frobably, however, it
is to physiology we shall have to look, in the end, for a solution of this difficult
question ; for pathology is strangely barren of results in this disease ; so much
so that it is doubtful whether the presence of sugar in the system either necessarily

1862.]

Medical Pathology and Therapeutics.

233

depends upon, or produces, visible organic lesion of any particular organ. When
organic diseases do exist, they are looked upon as merely concurrent affections.

However, it is not my intention to discuss the nature of diabetes mellitus : I
merely wish to give a brief account of how this saccharine plan of treatment
turned out in my hands, after a trial of more than four months.

Four cases of diabetes mellitus came under my care in hospital, almost simul-
taneously.

The first was a man named Thomas Eyan, aged 37, who had been diabetic for
thirteen months before admission, and had been under treatment for his disease
during the greater part of that time. On admission he was voiding, daily, eight
pints of urine, specific gravity 1049, and containing 22 grains of sugar in each
ounce. He complained of great thirst, languor, and debility; the skin and mu-
cous membrane were dry; the bowels confined; and all the usual symptoms of
diabetes were present.

I treated this man with Dover's powder and the vapour bath, for a fortnight,
when he left the hospital relieved in respect to the condition of the skin and
mucous membrane ; his thirst was abated, and the skin was somewhat moist ;
the quantity of urine varied with the amount of fluid drank, but its condition
was unaltered. He thought he was growing weak, and wished to go home. He
told me his father had a complaint similar to his own.

This man returned on the 18th of January, and was then voiding ten pints of
urine daily, of a specific gravity 1041, 24 grains of sugar in each ounce. He
said he drank a large quantity of beer, one day, at home, and was not as well
since. I now determined to put him on the saccharine treatment, and ordered
him six ounces of barley sugar daily; diet of fresh meat, with green vegetables
and bread ; also a moderate quantity of lime-water and milk. He continued this
plan steadily for three weeks ; and at the end of that period his condition was,
to a certain extent, improved. The quantity of urine passed was seven pints,
the specific gravity 1041 : each ounce contained 24 grains of sugar ; and he
gained two pounds in weight. The skin was somewhat moist, thirst abated.
He was again anxious to return home, and left the hospital.

The second case was a man, aged 40 ; but as he was not in the hospital more
than a week, and was treated with sudorifics (Dover's powder) alone, and almost
an exclusively animal diet — I will only refer to his case. In fact, he would not
submit to the abstinence from fluids, and the variety of food which I enjoined.
He left without any apparent change. There was one fact connected with him
of interest — he told us his father had the same ailment he was labouring under,
and died of it.

The next patient was a man aged 32 (John O'Neill), who suffered from the
complaint for 18 months before admission. On the 3d January he was voiding
15 pints of urine, of a specific gravity 1043, 18 grains of sugar to the ounce.
He was very thin, and had all the symptoms of diabetes in an aggravated form.
He was treated with sugar and a mixed diet, like the former patient ; and at the
end of six weeks his urine was reduced in quantity to six pints — the specific
gravity remaining the same. All the other symptoms were greatly relieved, and
he felt himself much better and stronger ; in fact so well that he was anxious to
go and resume his former employment (that of a shopman). Yet. on weighing
him, we found he had lost four pounds in weight since his admission, and his
urine contained 22 grains of sugar to the ounce. We heard that he since died
of phthisis.

The last and most interesting case is that of Henry ]S['Xee. He was a mar-
ried man, 30 years of age ; tall, well-proportioned, and of a very athletic frame.
He was always temperate; had no hereditary predisposition to the disease, and
attributes his illness to profuse perspirations and alternate chills while working
as a railway labourer. Five years ago, when employed in England, he first
noticed his disease, and was treated for it at the Manchester Infirmary. After
four months' stay in that institution, he left at his own request, relieved suflB-
ciently to resume his work, at which he continued for 11 months before admis-
sion. At that time he noticed the aggravation of his disorder, which set in
with great thirst, increased flow of urine, general weakness, and rapid loss of
flesh.

234

Progress of the Medical Sciences. [July

On admission, all those symptoms had attained a great intensity. He said he
was only the skeleton of his former self; for, when in health, he weighed more
than 14 stone, and now he did not reach 12 ; which surprised him, when he could
eat so much — four times his ordinary quantity — and he did not feel sick, only
very weak. He was voiding 10 quarts of urine in 24 hours, of specific gravity
1049, and was obliged to empty the bladder every hour. He drinks about the
same quantity of fluids within the same time. His urine has an acid reaction, is
free from albumen, and each ounce contains 24 grains of sugar. As an evidence
of his broken-down health we found a large, chronic, indolent ulcer over the right
external ankle.

I was determined to give the saccharine treatment an uncomplicated trial in
this case ; and, after an aperient, I put the patient on six ounces of sugar, daily,
together with four ounces of treacle ; bread, meat, and green vegetables for diet ;
lime-water and milk for drink — with an injection to limit the amount as much as
possible.

At the end of a month he was somewhat improved. He had gained two
pounds in weight; his thirst and appetite were diminished; the quantity of urine
passed in 24 hours was reduced from 10 to 7 quarts ; the specific gravity ranged
from 1043 to 1045 — 26 grains of sugar to the ounce.

During the next month he had two attacks of sudden and violent sickness of
stomach, accompanied with constant vomiting and cramps in the abdomen and
legs. He complained, for a few days, of great nausea, and felt as if saturated
with sugar ; everything, he said, tasted sweet. He was, at the same time, weak.
The urine was of a specific gravity of 1044 — not lessened in quantity. The ulcer
of leg was healed. The sugar treatment was discontinued.

After the lapse of a few days the sugar was again resumed ; and his condition,
at the end of another month, was as follows : His weight, 12 stone ll-lbs. ; con-
sequently he had gained nine pounds since last report. His urine is reduced to
three quarts in 24 hours ; and he is not disturbed more than once or twice to
pass it during the night. His skin is moist ; his bowels are regular ; he has
gained strength, for he is able to work at the force-pump of the hospital for an
hour without resting. The specific gravity of the urine is 1035-9, but it contains
a greater amount of sugar than before. According to Garrod's glucometer each
ounce contains 40 grains of sugar. His appetite and thirst have decreased; the
ulcer of the leg has broken out again.

After four months' stay, he left the hospital in the month of May, and obtained
employment as a porter, which obliged him to carry considerable weights ; he
remained at this work for six months, during which time I saw him occasionally ;
but at the end of that period he was completely prostrate, and sought relief in
another hospital. As the sequel of his case has been published, I will add some
extracts from the report : — ■

He was admitted into Dun's Hospital, under the care of Professor Law, in
the month of January, and was then voiding 16 pints of urine in 24 hours — spe-
cific gravity 1042. On the 10th of February the quantity of urine was 12 pints
— specific gravity 1035-9, and contained 8.750 grains of sugar, or about 45^
grains to an ounce. On the 8th of March the quantity of sugar was 39 grains
to the ounce, the amount voided being the same. On the 20th March the quan-
tity of sugar declined to 34 grains ; and on the 8th May the urine was reduced
to 10 pints ; there were 38 grains of sugar in each ounce.

He left the hospital in July; but was again readmitted late in October, in an
advanced stage of phthisis ; and on the 10th November the post-mortem exami-
nation showed extensive tubercular disease in both lungs. "Both kidneys were
very large ; one weighed 12|- ounces, the other 11. Both were much congested,
but exhibited no trace of disease or deviation from their normal structure. The
liver was perfectly normal in size and appearance : and, on examination, did not
contain a trace of sugar. It was, in fact, to the eye and to chemical analysis a
specimen of a healthy liver."

It will be seen from these cases in which the saccharine treatment has had a
pretty fair trial that, to say the least, it produced no permanent improvement.
'J'he specific gravity of the urine was not altered, and in each instance its sac-
charine quality was aggravated. Tis true the amount of urine voided within a

1862.] Medical Pathology and Therapeutics.

235

given period was considerably diminished ; but I think that result is very much
within the control of the patient, exclusive of medieine. I mean, of course, if
he checks his desire for fluids. The gain in weight and the increased strength
may be more justly attributed to other causes than to the amount of sugar taken ;
and I am quite satisfied, so far as my observation enables me to judge, that the
saccharine treatment of diabetes is not entitled to the credit which its advocates
claim for it. All that can be said for it is, that it is vastly agreeable to patients,
and is not positively injurious, as one might ci 'priori be inclined to suppose. —
Dublin Quarterly Journ. Med. Sc., May, 1862.

29. Chorea treated hy Sulphate of Aniline. — Dr. Morell Mackenzie reports
{Medical Times and G^aze^^e, March 8, 1862) five cases of chorea treated in the
London Hospital, under the care of Dr. Fraser, by the sulphate of aniline, and
in all it failed to relieve the symptoms.

Dr. Thos. Skinner reports in the same journal, for March 15th, another case
of failure of the sulphate of aniline to relieve chorea.

30. Individual Remedies in Epilepsy. — Dr. Anstie read a paper before the
Medical Society of London (March 24, 1862), in which he gave the results of
his own experience in the use of certain remedies in epilepsy. These were of
two kinds — tonics and sedatives : of the former he had made careful experiments
with cod-liver oil, quinine, and phosphorus, and also to a certain extent with
iron ; but of the effects of this last remedy he had not kept a tabulated record.
Ood-liver oil was employed alone in twelve cases among the out-patients of
Westminster Hospital and Chelsea Dispensary : the disease was in every instance
of the simple or " idiopathic" kind ; and the following results were obtained:
Three complete failures (patients aged 14, 26, and 32, respectively ; in all of them
the disease was of long standing) ; one case in which the patient, a man, aged 44,
derived no relief as far as regarded the fits, but his mental condition was im-
proved ; two cases (aged 10 and 12) which were improved, the fits being lessened
in frequency, but the patients disappeared from the author's supervision while
still by no means cured ; and, finally, six cases, all still under observation, in
which the fits have ceased entirely, and, so far as can be seen, the disease has
been cured. Out of these six cases, two were sufficiently grave to put the efficacy
of the remedy to a severe test ; one of them was that of a girl, aged 17, epileptic
from infancy, and in whom the fits had for some time past been happening two
or three times every day ; the effect upon the facial aspect and upon the intel-
ligence of the patient had been very serious. Cod-liver oil was employed per-
sistently for three months with the effect of inducing an entire cessation of the
fits, and a most marked improvement in the intellectual and sensorial functions.
The other case was that of a boy, aged 13, in whom the disease, which was here-
ditary, had come on six months previously. The fits were not very frequent, but
were very severe ; the memory was a good deal affected, and the shape of the
head and the aspect of the face were far from encouraging. Nevertheless, a
complete cessation of the fits soon followed the use of cod-liver oil. The remedy
was persisted in for six months on account of occasional threatening symptoms ;
but even these have quite disappeared. The mental condition is much improved,
and the boy may be pronounced cured, as far as we dare use that term at all.
Quinine had been used singly in six cases : two of them had entirely resisted its
influence (both these patients were women), a third had been very much bene-
fited, the fits being much reduced in frequency, and an unpleasant numbness in
the leg having disappeared. In the other three the improvement apparently
amounted to cure. One of these cases, in which a very marked and peculiar
aura was present, was minutely analyzed, and the influence of the quinine in
stopping the aura, and altogether averting the paroxysms, was plainly shown.
DoulDtless local measures might have done much in this case, but they were
intentionally and successfully dispensed with. All the cases treated by the
author with quinine had been distinguished by the presence of some persistent
local pain or numbness. Phosphorus had been tried by the author in only two
cases of epilepsy, at the suggestion of his friend and colleague. Dr. Radcliffe,
who has recommended its use in his book, as also that of cod-liver oil. The cases

236

Progress or the Medical Sciences.

were inveterate ones, in wHcli cod-liver oil had failed to produce any effect. The
phosphorus was given in doses of five to ten drops of the phosphoretted oil of
the Prussian Pharmacopoeia, three times a day. The fits were not lessened in
frequency, but the general condition of the patients was much improved, and
the miserable sense of nervous depression greatly relieved. Phosphorus ought
to be extensively tried in epilepsy and in other nervous affections. With regard
to iron, the author not having kept tabulated reports of its effects, was only able
to confirm, in a general way, the popular belief in its great utility. He was in
the habit of limiting its employment to cases distinguished by anaemia ; and he
related one or two instances of its usefulness when given in such cases. The
author remarked that all these four tonics, cod-liver oil, steel, cjuinine, and phos-
phorus, were distinguished by the fact that they acted as foods, either to the
nervous system, or the blood that nourishes that system. Looking at the success
obtained by himself, and by other observers of larger experience, and also to the
fact that the whole group of chronic convulsive diseases, of which epilepsy may
be said to form the centre, are curable, if at all so, in nine cases out of ten by a
nutrient-tonic regimen — the author urged that there was the greatest reason for
extended experiments with remedies of this class, experiments which should be
patiently persisted in for months together, no other medicines being used, except
aperients when necessary. The sedatives of which the author had made par-
ticular trial were opium, hyoscyamus, belladonna, and sulphate of aniline. With
regard to belladonna, he must state that he had not thought it right to push it
to the extent of producing wide dilatation of the pupil for a long time together.
He had administered it in doses of one-sixth grain of the extract twice or three
times a day, a quantity which is usually sufficient to produce the minor effects
of the drug, namely, relief of neuralgic pain, and resolution of muscular spasms ;
and in these doses the results were very equivocal, and by no means encouraging.
With regard to the other three sedatives, the author regarded it as proved by
his own experience, that in a considerable number of instances they possess the
power of delaying the fit, or mitigating its severity; and for this purpose he was
at present inclined to give the preference to the sulphate of aniline. This remedy
he had tried repeatedly upon six epileptic patients, and also in many other cases
of chronic convulsive disease. It was a most serious mistake to administer sul-
phate of aniline, or indeed any other sedative, in large doses, with a view to arrest
or diminish convulsive muscular action. In the only two cases of epilepsy in
which the author had pushed it to the extent of large doses, on account of the
failure of small quantities, a serious aggravation of the fits occurred. In doses
of one grain three times a day, with an additional grain to be taken immediately
on the occurrence of anj prodroinata of a fit, sulphate of aniline seemed to ma-
terially benefit four patients to the extent of delaying or mitigating the paroxysm,
and in three separate instances the fit seemed to have been altogether averted
for a considerable time.

In conclusion, the author desired to state his conviction that future experi-
ments with sedatives should be limited to the use of small doses only, and that
they should be employed chiefly in the slighter cases of epilepsy which are not
of long standing, or in those in which tonics and nutrition had already done much,
but had not quite effected a cure. In short, wherever we could reasonably hope
to effect good by the mere fact of breaking through the vicious habit, so to speak,
of convulsion ; then we might well try experiments with sedatives, and the results
obtained by each observer should be numerically noted, and published. — Med.
Times and Gaz., April 5, 1862.

31. Statistical Inquiry into the Prevalence of Numerous Conditions affecting
the Constitution in one thousand Phthisical Patients when in Health. — Dr.
Edward Smith read a paper under this title to the Royal Medical and Chirur-
gical Society (March 25, 1862). After some preliminary remarks, the author
described the method which was pursued in the inquiry, and offered an estima-
tion of the trustworthiness and value of the answers which he had recorded.
There were 600 male and 400 female cases, all attending at the Hospital for
Consumption, and in the stages of marked consolidation or destruction of the
lungs. He then quoted the scheme of inquiry proposed to each patient, con-

1862.]

Medical Pathology and Therapeutics.

237

sisting of 138 queries, aud the following is a summary of the facts obtained :
The average age of the patients was 28.8 years. 30 .per cent, had been born in
London, 36 per cent, had lived chiefly in London, and 53 per cent, had lived in
London during the preceding three years. 8.8 per cent, could not read nor
write, and only 14.3 per cent, had been insufficiently nourished. 1. Parerital
conditions. — 54 per cent, had lost the father ; 46 per cent, the mother ; and 28
per cent, had lost both parents. In 25 per cent, only were both parents living.
The average age of the parents at death was 50.8 years, with an increased dura-
tion of 4.7 years on the part of the fathers. The most frequent age at death
was 35 to 55 years ; whilst only 11 per cent, died under the age of 35, and some
lived upwards of 95 years. 18 per cent, had experienced feeble health before
the birth of the patient, and 34 per cent, throughout life. In 22.7 per cent, one
or both parents had led unsteady lives. 21.1 per cent, of the parents had died
of consumption ; whilst in 2.8 per cent, the grandparents, 23.3 per cent, the
brothers or sisters, and 9.1 per cent, the uncles or aunts, had died of the same
disease. They had suffered from rheumatism in 22 per cent., from asthma in

9.4 per cent., from liver disease and gout in 9 and 7.2 per cent., and from fevers,
ague, insanity, and diabetes in 4 and 5 per cent. Presumed scrofulous affections
were extremely rare. In only six cases was there consanguinity of the parents.
The age of the parents at the birth of the patient was in half of the cases from
25 years to 35 years ; and in only 2 per cent, was it less than 20 years. The
number of the children was very large, viz., an average of 7.5 to a family, and
in some families there were 23 children. The patient was the first child in 20
per cent. ; and the first, second, or third child in half of all the cases. 40 per
cent, of the parents' children had died. 2. Personal conditions. — In only 23 per
cent, were the patients under 20, and a few were 60 years of age. 24 per cent,
had been feeble at birth, whilst 22 per cent, had suffered from feeble general
health and 17 per cent, from generally defective appetite. In 12.6 per cent, the
lungs had been always delicate; 2.5 percent, had been dry nursed; 25.4 per
cent, had perspired with unusual freedom ; 25 per cent, had never worn flannel
next the skin; and 55 per cent, had suffered from coldness of the extremities.
72.5 per cent, had an excitable temperament ; 62.1 per cent, had medium brown,
or light-coloured hair ; 74 per cent, had gray or blue eyes ; 60 per cent, had
florid complexions ; and 46.7 per cent, had a fleshy habit. 16, 65.4, 60, and 41
per cent, had not had measles, scarlet fever, smallpox, and whooping-cough in
their order ; and the frequency of any long-continued ill-efiects from these dis-
eases was insignificant. 12.8 per cent, had suffered from enlarged glands, and

4.5 per cent, from long-continued affections of the eyes ; but otherwise the evi-
dences of scrofulous disease scarcely existed ; 16.7 per cent, had suffered from
inflammation of the lungs, and 14.8 per cent, from rheumatism ; whilst typhus
fever and frequent diarrhoea had occurred in 8 per cent., ague in 5.6 per cent.,
and Uver disease in 4.3 per cent, of the cases. The menstrual epoch was at the
age of 14 and 15 in 36.4 per cent., and in 11 per cent, only was it before the age
of 13; 40 per cent, had complained of general irregularity, and in 29 per cent,
the quantity was insufficient. Leucorrhoea was considerable in 42.2 per cent.
43.5 per cent, were married ; and of these, 13 per cent, were childless at the
period of inquiry. Their average age at the birth of their first child was from
20 to 25 years, and in only 9 per cent, were they under 20 years. The number
of children per family was 1 and 2 in 44 per cent., and 1, 2, and 3 in 55 per cent,
(the patients' average age was 28.8 years). 38 per cent, of the children had
died, and in 43 per cent, the general s^tate of the health of the children was bad.
Abortions had occurred in 46.2 per cent, of the child-bearing married women,
aud some had suffered eight abortions. 11.6 per cent, of the males had com-
mitted sexual abuse ; 18.2 per cent, had been addicted to masturbation, and 22
per cent, had suffered from involuntary emissions. 16 per cent, had syphilis,
and 38.5 per cent, gonorrhoea; one on several occasions. 29.6 per cent, had led
a bad life at some period, 24.5 per cent, had drunk to excess, and 48 per cent,
had smoked tobacco ; 19.3 per cent, of both sexes had submitted to late hours,
and 22.2 per cent, had suffered much anxiety. In 70 per cent, there was some
complaint as to the injurious influence of their occupations, and of those causes,
exposure, long hours, close and hot rooms, bending postures, and dust or fumes,

238

Progress of the Medical Sciences.

[July

were complained of in 32.1, 28.6, 24.4, 20, and 15.8 per cent, in their order. 9
per cent, had taken mercury largely, and 54.4 per cent, had been bled at the
arm from 1 to 12 times. The author then considered some of the most important
truths which the inquiry had evoked, and particularly the questions connected
with hereditary transmission ; the especial liability of the female sex to many of
the conditions pointed out, and the state of the system ; the diseases and the
effects of the immoralities of life upon the patients. With regard to the greater
liability of females over males, it was shown, in reference to parents, that more
mothers than fathers who had children early, had feeble general health, and had
died early. More female than male patients had mothers who died early; had
most relatives who had died of phthisis ; had parents with one child only ; had
experienced feeble health and defective appetite throughout life ; had had deli-
cacy of the lungs ; had married when very young ; had feeble children ; had lost
most children; had suffered from anxiety; had had measles, scarlet fever, and
whooping-cough ; had not worn flannel next the skin ; had a very defective edu-
cation ; were of susceptible temperament ; had brown eyes, florid complexion,
and fleshy habit, and had suffered from coldness of the extremities. — Medical
Times and Gazette, April 5, 1862.

32. Brass Founders' Ague ; Disease 'produced hy Fumes of Zinc. — Dr.
Greenhow, in a paper read before the Eoyal Medical and Chirurgical Society
(Feb. 11, 1862), stated that this disease had first fallen under his observation
during a brief holiday visit to Birmingham in the autumn of 1858, and he had
subsequently been able on several occasions to investigate its history and causes
in Birmingham, Wolverhampton, Sheffield, and Leeds. The symptoms have, as
the name implies, some resemblance to an imperfect paroxysm of ague ; but they
differ from it in this respect, that the paroxysms occur irregularly, and are dis-
tinctly traceable to exposure to the fumes of deflagrating zinc. The attack
commences with malaise, a feeling of constriction or tightness of chest, some-
times accompanied by nausea. These always occur during the after-part of a
day spent in the casting-shop, and are followed in the evening or at bed-time by
shivering, sometimes succeeded by an indistinct hot stage, but always by profuse
sweating. The sooner the latter follows the setting in of the cold stage, the
shorter and milder is the attack, and the less likely is the caster to be incapaci-
tated for work on the following day. Headache and vomiting frequently, but
by no means always, accompany the attack, which at the worst is only ephemeral ;
but the attacks are sometimes of frequent occurrence. Persons who have but
lately adopted the calling, or who only work at it occasionally, and regular brass
founders who have been absent from work for a few days, are more liable to suffer
from this disease than those who work at it continually. The men themselves
attribute this disease to inhaling the fumes of deflagrating zinc, and there can
be no doubt that their opinion is correct ; for, on the one hand, several other
classes of operatives are habitually exposed while at work to conditions exactly
similar to those of the brass founders, except the liability to inhale the fumes of
zinc, and yet do not suffer from this ailment ; and, on the other hand, brass
founders suffer from it in almost exact proportion to their liability to inhale
these fumes. The results arrived at by the author of the paper are — 1st. That
brass founders, and, doubtless, other operatives exposed to the fumes of defla-
grating zinc, are liable to suffer from symptoms resembling an irregular kind of
intermittent fever. 2d. These symptoms consist of malaise, listlessness, aching
of the limbs, nausea, headache, and shivering, with occasional vomiting, followed
sometimes by febrile reaction, but always by profuse sweating. 3d. The severity
and frequency of the attacks are much influenced by the regularity with which
men work in the casting shops, those who work steadily at the occupation
appearing to acquire a tolerance of the poison, which is, however, only tempo-
rary, seeing that after a few days' absence from work even the most seasoned
casters are apt to have an attack of the metal ague on being again exposed to
the fumes of deflagrating zinc. 4th. The severity and frequency of the attacks
depend mainly upon the quantity of zinc fumes evolved into the atmosj)here of
the casting shops, those men who mix the metals, and especially those who use
a large quantity of zinc in their castings, being much more liable to sufifer than

1862.] Medical Pathology and Therapeutics.

239

those who merely re-melt brass bars, or make brass containing- but a small pro-
portion of zinc. 5th. Any cause which tends to retard the dispersion of the
fumes into the atmosphere — such as a close ill-ventilated workshop, or foggy
weather, or a high wind that beats back the fumes into the shop — increases the
liability of the casters to suffer from metal ague. 6th. Although the cold stage
is usually preceded by well-marked prodromata, slight causes, such as getting
into a cold bed, or any trifling derangement of the health, are apt to excite a
paroxysm of brass founders' ague in persons already predisposed to it by habitual
exposure to the fumes of deflagrating zinc. 7th. Operatives, such as makers of
galvanized iron-ware, who work over molten zinc below the temperature of
deflagration, enjoy an entire immunity from this disease. — Med. Times and Gaz.,
March 1, 1862.

33. Sudden Death/mm Emboli. — A woman, 27 years of age, whose occupa-
tions compelled her to be constantly standing, had suffered for several years
from large varices, which occupied the left saphena vein from the foot to the
bend in the groin. At the end of November she was affected for the third time
with inflammation of the saphena, and entered the Charity, under M. Briquet.
The vein throughout its whole course and principal divisions was completely
filled with coagulated blood, constituting large indurated cords, the skin cover-
ing them being red and thickened. By position, emollients, and similar means,
the inflammation and fever were got under, and the patient was thinking of get-
ting up in a few days, when on December 8, after an excellent night, she was
seized by an undefinable sensation, and uttered a cry of alarm. She was found
to be extremely pale, her features having undergone marked changes. Her
arms were convulsively moved, she complained of intense pain in the chest, and
in a state of the greatest alarm declared she should be suffocated. The pulse
was filiform, the heart beat tumultuously, but without abnormal sound, and she
died at the end of twenty minutes. The external saphena, as well as its prin-
cipal divisions, was filled by a hard, blackish coagulum, which adhered to the
reddened walls of the vein, and extended as far as the commencement of the
left iliac vein. The deep saphena was free, and the blood it contained was quite
fluid. The iliac vein and the vena cava were quite free from obstruction, and
nothing abnormal was found in the heart or its cavities. But when the pulmo-
nary artery was opened, a coagulum was found folded back upon itself, and
occupying all the space between the sigmoid valves and the bifurcation of the
artery. The coagulum was quite free within the artery, and the walls of this
vessel, as well as all the endocardium, were perfectly white and polished. The
coagulum, fifteen centimetres long, was of a much less diameter than that of the
artery, its calibre being that, in fact, of the iliac vein. It in nowise resembled
the concretions which are sometimes found in the pulmonary artery, being red
and very hard, and consisting internally of coagulated fibrine. The lungs were
pale, and almost bloodless ; and there were no other appreciable morbid changes.
The deep veins of the leg and thigh were of normal volume and appearance,
and contained only fluid blood. There can be no doubt, M. Briquet observes,
that a coagulum detached from that which filled the femoral vein, was carried
into the iliac vein under the influence of the ascending venous current. Re-
maining movable and unattached to the walls of the iliac vein, when the patient
was placed in the horizontal posture it entered the heart, and thence the pul-
monary artery, when applied against the arterial bifurcation, it simultaneously
arrested circulation and respiration, and gave rise to sudden death by syncope
and asphyxia. — Med. T. and Gaz., March 22, 1862, from Gaz. des Hop., No. 25.

34. Case of Syphilitic Disease appearing in two Healthy Children after
Vaccination from a Syphilitic Child. — Dr. N. J. Haydon relates [Med.. Times
and Gaz., March 29, 1862) the following examples of this, which are interesting
as bearing upon the question now in dispute as to the possibility of syphilis being
communicated with the vaccine virus : —

"In the summer of 1843 1 was called, as the medical officer having charge of
the sick poor of the parish and borough of Bodmin, Cornwall, to attend" two
young children of different families, and living about a quarter of a mile distant

240

Progress of the Medical Sciences.

[July

from each other. The children were each of them from nine to ten months old.
The history of their illness being precisely similar, one description vrill apply to
both. On the first introduction of the compulsory vaccination system, the guar-
dians of the Bodmin Union entered into a contract with one medical man to
perform the vaccinations for the whole Union. This gentleman, in the discharge
of his duty of public vaccinator, attended at the appointed room in Bodmin, and
on that particular day vaccinated those two children, taking lymph from the arm
of a child he had vaccinated the preceding week ; he appeared (from the most
careful personal investigation which I made of this matter at the time) to have
vaccinated no other than those two children on the day in question, and to have
taken lymph from no other child, but the particular one alluded to. Between
the second and third week after the vaccination had been performed, I first saw
the children. They were literally covered with large phlyzacious pustules, the
irritation was most intense, and, between rubbing and scratching, the head and
nates were raw and ulcerated. No treatment had any avail, and both these poor
children died a few days after I first saw them. Being at once impressed that
the disease of these children was syphilitic, I made the most carefal investigation
I could into the whole matter. In both families there were other older children
perfectly healthy. The parents, in both cases, were labourers, of most healthy
appearance, and of good character ; were then, most certainly, and I have no
cause to doubt ever had been, free from syphilitic taint. The respective mothers
of both children carried their infants themselves to be vaccinated : they saw the
operation performed, and they saw the child from whom the lymph was taken;
they told me the name of the child, and where it lived. As medical officer of the
borough of. Bodmin, this child and its mother were both known to me. The
mother had been, and, in fact, then was, on the town, and I had attended her for
syphilis. At that very time she was diseased. I examined her child ; it had, as
far as I could see, no primary syphilitic sores, but it had numerous syphilitic
eruptions about its body, pustules about its nates and trunk, and copper-coloured
leprous spots. The child was between two and three years old. and under treat-
ment it recovered. The public vaccinator lived at a distance from Bodmin, and
could not have known the character of the parties from whom he took the
lymph."

35. Value of ^gopliony as a Sign of Pleurisy. — Laennec considered aego-
phony as a pathognomonic sign of pleuritic effusion. Skoda was the first to call
in question this, but it remained to Prof. Landouzy to show that aegophony is
due not to the fluid, but only to the modifications produced in the lung by the
fluid. In a work published some years ago, he said. "^Egophonyis only a
variety of bronchophony : it is dependent upon the modification impressed upon
the lung by the effusion, but not upon the fluid itself." The professor now pub-
lishes two additional cases, which, though at first sight contradictory, demon-
strate the real conditions upon which aegophony depends.

The following are Prof. L.'s conclusions : —

1. ^gophony indicates compression of the lung, either by a fluid effusion in
the pleura, or by a layer of false membrane without actual effusion.

2. In the absence of resisting false membranes, segophony disappears or dimi-
nishes on the removal of the effusion.

3. When false membranes are present, segophony increases immediately after
thoracentesis, but diminishes gradually with the yielding of the membranes. —
Ed. Med. Journ., April, 1862, from Archives Generales, December, 1861.

36. Tcenta Solium. — M. Mauche has observed twenty cases of t(E7iia solium
among the soldiers of the 16th battalion infantry chasseurs, recently returned
from Syria. Most of the patients have expelled slender portions of the para-
site, with or without the head, armed with three hooks, the distinctive character
of the T. solium. One patient only passed two whole worms. The kousso
succeeded almost always when the three following precautions were taken: 1st,
that fragments of the worm should have been passed shortly before commencing
the use of the medicine ; 2d. that the kousso is prepared the day it is to be
taken; 3d, that the patient observes a rigid diet for from 12 to 2i hours pre-

1862.]

Medical Pathology and Therapeutics.

241

viouslv to taking the medicine. The decorticated fresh seeds of the pumpkin
rubbed up with sugar were used in some cases. This remedy was longer in
expelling the worm and less effectual. It generally did not expel the worm
earlier than 24 to 30 hours. The anthelmintic opiate composed of 125 grammes
of honey and 20 grammes of turpentine also was useful, but it was less certain
than the kousso. — Joimi. Heodom.. 24 March, 1862, from Becueil de M6m, de
M6d. de Chirurg. et de Pharm. Jlih't., torn. vii. 3d serie.

37. On the P rohabilities of the Duration of Life in the Apoplectic ami the
Phthisical — Dr. Beuckxer has collected materials for determining statistically
the probabilities of life in the apoplectic and phthisical.

The results of his observations in the case of persons threatened with apoplexy
are the following : Fatal cases of apoplexy are on the increase; therefore the
danger in our day is greater than it was in the last century. Hamburg appears
to be the most dangerous residence for such persons ; London is safer ; moun-
tainous countries are the safest. The country is less dangerous than towns.
Winter is the most dangerous period for these persons ; spring and autumn are
less dangerous ; summer is the safest. The first year of life presents the greatest
danger from this cause ; it goes on diminishing till the tenth year, and increases
rapidly from fifteen to twenty. From this time it increases more slowly up to
forty years, when it increases rapidly. About the sixtieth year the greatest
increase of danger takes place ; it only increases slowly from this time to seventy-
five. From this age, the danger of apoplexy gradually diminishes. The years
48, .i8, 66. are peculiarly dangerous. On the other hand, there is little danger
of dying of apoplexy in the years 46 and 49. The male sex is (with the excep-
tion of London) generally more exposed to apoplexy than the female, particularly
between the ages of thirty and fifty: whilst up to twenty, and then after sixty,
there is proportionally more danger for the female sex. During the middle and
earlier years of life, the well-to-do classes are in greater danger of apoplexy than
the population in general. TThere intermittent or pituitary fevers prevail, the
danger appears to be greater. Sudden change of weather appears to increase
the danger, as also does rain, whilst fogs (London) do not appear to have this
eff'ect.

TTith regard to the probabilities of being attacked with and dying of phthisis,
Dr. Bruckner's inquiries give the following results : The danger of death from
phthisis is not so great at present as it was in former times. The female sex is
in greater danger of phthisis than the male : London and Berlin are exceptions.
This is particularly the case in youth, and up to the fortieth year; whilst in later
life the danger diminishes more rapidly in the female sex than in the male.
Persons who. from the nature of their employment, are exposed to the inhalation
of dust, especially of mineral particles, are in great danger. Those who freely
employ the organs of voice, or the muscles of the chest, particularly in the open
air, are exposed to the least danger. Phthisis appears to be most frequent in
the two temperate zones. In countries where inflammatory affections of the
chest are endemic, the danger of phthisis is inconsiderable : these diseases, when
endemic, exclude one another. In countries where intermittent fever is endemic,
the danger of consumption is great: these diseases do not exclude one another.
At "a height of 1800 to 3000 feet above the sea (in dry mountain air), the danger
of becoming phthisical is slight ; in low marshy districts, on the other hand, the
danger is great.

With regard to the probable duration of life of such persons as are doomed,
to die of phthisis, Dr. Bruckner has deduced from his statistical investigations
the following conclusions : In a person of phthisical constitution, the dauber of
becoming affected with consumption increases up to the twentieth year, when it
has reached its highest point. The danger may be reckoned as equal to 21.05
years of life, so that such a person at the age of 23 years has the same expect-
ancy of life as a healthy individual at 44. From the thirtieth year, when it may
be reckoned as equivalent to 17.42 years of life, the danger goes on diminishing.
In the fortieth year it is equal to 13.94 years, in the fiftieth to 7.23 only. In the
seventieth vear the danger is at an end, a person of a phthisical constitution
No. LXXXYIL— July 1862. 16

242 Progress op the Medical Sciences. [July

having the same prospects of life as any other individual of that age. Under
similar circumstances, phthisical persons of the female sex die more rapidly and
at an earlier age than males. The female sex reaches some years earlier than
the male its highest point of mortality from phthisis.

If a person is actually affected with phthisis, his probable duration of life is
21 months and 9 days. A pregnant woman, during the duration of her preg-
nancy, is not likely to die of phthisis. After delivery, a consumptive woman
has probably not more than six weeks to live. For all phthisical persons, the
danger of dying is considerably greater in spring, less in summer and winter,
and least of all late in summer, towards autumn. If a phthisical person removes
from a warm to a cold climate, the danger of death is thereby greatly increased.
— Edin. Med. Journ., Jan. 1862, from Canstatfs Jahreshericht, 1861.

SUKGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIVE

SURGERY.

38. Treatment of Burns. By Prof. Roser. — In truth, there can scarcely be
said to be any special treatment of burns, the loss of substance resulting from
their influence being repaired by the same processes as prevail after any other
form of destruction of the cutaneous surface. Much depends upon the depth
to which the injury has extended, for while a destroyed epidermis is rapidly
reproduced, when the skin has suffered to a great depth, or throughout its
entire substance, the reparation, after the separation of the mortified parts,
may be very tedious, in consequence of the great loss of substance, or of the
unsuitable character of the parts affected for cicatricial formation. The con-
traction after cicatrization is also often great, both from this loss of substance
and from the position of the parts, as in the bend of the limbs, being favourable
to such contractile action. It is, however, an error to suppose that greater con-
traction follows burns than takes place from similar loss of substance from other
causes. When the skin has been destroyed only through a portion of its sub-
stance, this contraction is not observed, only smooth cicatrices analogous to
those of smallpox being present.

Not only is the- period required for reparation and cicatrization after burns
dependent upon the depth to which the injury has extended, but it is still
more so on the inflammation of the skin which it has given rise to. This may
affect not only the part actually burnt, but the adjoining parts, and may give
rise to a secondary destruction of the skin, or at all events obstinate suppu-
ration, which will delay the healing process, this then assuming a remarkably
chronic character. Although it is this last circumstance which by its complexity
and its consequences chiefly renders our prognosis uncertain, yet the other
point, the determination of the depth to which the burn has extended, is by
no means always an easy matter at first, even for the most experienced observer.

When the epidermis is merely lost or raised up into bullae, the treatment of
burns is simple enough. The serum should be discharged from the bladders by
small punctures, without removing the epidermis. The necessity of covering
the exposed nervous papillse explains the success of various empirical applica-
tions ; and even the solution of nitrate of silver acts only in this way. The
exposed cutis becomes covered with a thin layer of gelatinizing albumen, and
the deposit which ensues upon the application of the nitrate solution produces
a protective crust. Lead and chalk waters act in the same way, and cotton
wool, the most suitable and simplest of all dressings, thus protects the exposed
parts from the action of oxygen, and from mechanical contacts.

After two or three days, the physiological condition of the parts is different,
the exposed papillae having, in consequence of a growth of cells and vessels,
become covered with a protective covering. The excessive sensibility has
diminished, suppuration may have occurred, and perhaps here and there, deeper
penetrating inflammatory action has been set up. We have now to seek whether

1862.]

Surgery.

243

we can moderate this inflammatory action, and favour the formation of epider-
mis. But, in fact, we can do little in the matter. If the injury is superficial,
the healing will soon take place, under the use of the most different and some-
times absurd means ; while if the inflammation has penetrated deeply, do what
we will, the cure will be slower. We may resort, according to circumstances,
to various local antiphlogistic applications. When the mortification of the skin
is only superficial, it is quickly thrown off, leaving a retiform granulating surface,
and art has here little to do beyond protecting the parts from injury. When
the mortification extends deeper, we have no specific means for hastening the
suppuration of parts which must precede separation. Such separation is a phy-
siological process, and our intervention is limited to the prevention of its being
obstructed. But the separation having taken place, have we any means of
hastening the growth of granulations or of repressing them when too luxurious ?
Physiology and clinical experience alike declare that nothing need be done.
The granulations, if too prominent, will afterwards recede without the aid of
caustic ; and the smoothest cicatrices will be found in those cases in which least
interference has taken place. When, however, the wound is advancing towards
cicatrization, the condensation of the connective-tissue, and its covering with
epidermis, are much favoured by a protective covering of adhesive plaster.

In the extremest degree of burns, when the skin is destroyed throughout its
entire substance, we have to do with a condition of great surgical importance,
cicatricial contraction, which although of the highest utility in lessening the
surface of the wound in some cases, proves in others of the most serious detri-
ment. The employment of adhesive plaster is of great service in regulating
this contractile power of the cicatrix. Thus, suppose a longitudinal loss of
substance on the anterior surface of the index finger exists, there is no better
means of regulating the direction of the cicatrix which will ensue, than sur-
rounding the whole finger by small strips of plaster. These act in three ways.
1. The circular application displaces the skin from left to right, and favours the
formation of the cicatrix in the transverse direction, in which no contraction
can occur. 2. Contraction in the longitudinal direction is also prevented by
the finger being kept stiffly bound up" so that its flexure is difficult. 3. The
plaster exerts a very decided influence in preventing or remedying that projec-
tion of the cicatrix, which is so remarkable after longitudinal loss of substance
at the bend of joints and in the neck. In the same manner, in the most various
parts of the body, we may obtain from the use of plaster beneficial effects which
no other means will furnish. So also the contractions supervening on burns
which have been improperly treated, are so easily, rapidly, and completely reme-
died by the methodical application of plaster, that the cases must be seen to
obtain belief. Most aggravated cases, which those unacquainted with this sim-
pler means would suppose to be amenable only to the knife, and others for which
this has been in vain resorted to, have readily yielded to the application of
plaster. It was Mr. Tamplin who first drew attention to this mode of treat-
ment, and Professor Poser's experience has amply confirmed the truth of his
statements. He has been quite astonished at the success which attends the
treatment of the worst cases of contraction of the fingers. The plan consists
essentially in surrounding the part with small strips of plaster, and making
counter-pressure at the contracted flexures by means of small balls of cotton
wool. — Brit, and For. Med.-Chmrg. Review, April, 1862, from Archiv. der
Heilkunde, No. 1, 1862.

39. Traumatic Tetanus cured by Chloride of Barium. — Dr. Gnecchi, of
Milan, relates the following example of this : —

A hairdresser, thirty-nine years of age, cut himself in the palm of the left
hand, about the beginning of March, 1858. The wound healed in six days, and
there was no bad consequence until the morning of the 30th of March, when, on
getting out of bed, he began to feel a difficulty in opening the mouth, a contrac-
tion of the left hand with impossibility of extending it, with pain in the right
flank and thigh. For the first few days these symptoms disappeared when the
patient lay down in bed, but returned when he got up and exposed himself to
the air. On the 10th of April, as the symptoms were increasing in severity, the

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Progress op the Medical Sciences. [July

patient was admitted into the principal hospital of Milan. Next morning there
was spasmodic contraction of the masseters, with rigidity of the muscles of the
neck ; the left hand contracted as soon as the arm was removed from below the
clothes, while the pain in the flank and thigh persisted. The pulse was but little
increased in frequency. Chloride of barium was prescribed in the form of six-
teen grains of the salt in a pound of distilled water, to be taken in the course of
the twenty-four hours. This dose was continued till the 31st, when, as the
tetanic symptoms had almost disappeared, it was reduced to eight grains. The
medicine was discontinued after the 26th April, and on the 28th the patient was
dismissed cured.

In connection with this case, it may be stated that Dr. Gnecchi has since
succeeded several times in curing traumatic tetanus with this preparation of
barium, that Dr. Gherini failed, but that Dr. Tassani succeeded in the case of a
man wounded in the Italian war. — Ed. Med. Journ., April, 1862, from Gazette
3Ied. Ital. Comb., and Gaz. des Hop.

40. The Ififluence upon the Growth of the Bones of Paralysis, Disease of
the Joints, Disease of the Epiphysial Lines, Excision of the Knee, Rickets, mid
some other Morbid Conditions. — Dr. G. M, Humphry read a paper under the
above title before the Royal Medical and Chirurgical Society (April 8, 1862).
It consisted chiefly of the account and measurements of numerous cases and
specimens, and the following are the principal conclusions : Paralysis is usually
attended with a deficiency in the growth of all the bones of the part affected ;
this is most marked in the segments where the paralysis is most complete. Its
effect, however, is very irregular. Disease of an important joint, causing anchy-
losis or preventing movement in the joint, is often attended with imperfect
growth throughout the limb, most marked, however, in the segments contiguous
to the diseased joint. It is probable that anchylosis of the hip, in childhood,
may induce deficiency of growth on that side of the pelvis, and so be a cause, in
the female, of difficult parturition. The author has not, however, been able to
substantiate that point, and would be obliged by information bearing on the
question. Disease in the epiphysial lines of bones deserves more attention than
has usually been given to it. It is often, though not always, followed by impair-
ment of the growth of the bone affected, and sometimes of the whole limb. It
is most frequent and most deleterious at the lower end of the femur, where the
growing process is more active and longer continued than in any other part of
the body. In a segment of a limb where there are two long bones, as the fore-
arm or leg, and one of them is stunted by disease, the other commonly is so too,
but not necessarily. Thus the fibula sometimes outgrows the tibia, and runs
below, or ascends above, its proper level with regard to it. Excision of the
knee, if the epiphysial lines are removed, is followed by marked arrest of growth
in all parts of the Hmb. If the epiphysial lines are spared, the growth, in most
instances, keeps pace with that of the opposite limb. In some cases this is not
so, owing, perhaps, to the effect of the preceding disease upon the limb, or to
the epiphysial lines becoming involved and destroyed in the suppurative pro-
cesses that follow the operation. Hence the proper growth of the limb, after
excision, cannot be calculated on with certainty in any particular case. Still
the short limb, even when there is a considerable difference between it and its
fellow, is commonly so useful that the fear of arresting the growth of the limb is
not a fatal objection to the operation in young subjects ; and, after the age of
fifteen or sixteen, it need scarcely to be taken into account. Rickets is charac-
terized by a want of proper growth in bones, even more decidedly and more
uniformly than by preternatural curvatures in them. The imperfection is com-
monly noticeable, more or less, in all parts of the skeleton ; but is most marked
in the limbs, and most of all in the proximal segments of the limbs. These
segments of the limbs — i. e., the thigh and the arm, grow more quickly after
birth than other parts of the body ; and the want of growing power attendant
on rickets tells accordingly in a peculiar manner upon them. A bulging and
knottiness at the epiphysial lines is a common feature in rickets, and is apt to
be mistaken for swelling of the ends of the bones, which is very rare, except in
the intra-uterine and infantile periods. This bulging is due to the calcification

1862.]

Surgery.

245

of the epiphysial stratum of cartilage not taking place in a proper manner, so
that the part yields, or is squeezed out, and then undergoes ossification. The
condition is most frequently observed at the lower end of the femur and at the
upper end of the humerus. — Med. Times and Gaz., April 19, 1862.

41. Ligature of the Common Carotid. — Dr. Redfern Davis, of Birmingham,
communicated to the Medico-Chirurgical Society of Edinburgh the following
case : —

" About two years ago I was sent for during the night by a physician, to see
a man, who, in a paroxysm of jealousy, had just cut his throat with a pocket-
knife.

" When I arrived, I found the patient lying on a bed, whither he had been
removed. On the floor of the room was a large quantity of blood, and the bed-
clothes were sprinkled with the same fluid. The man, who, from loss of blood,
was very pale and feeble, presented on the left side of the neck, just below the
angle of the jaw, a rugged, transverse incision of about two inches in length.
The windpipe and gullet were uninjured. For about half an hour I vainly
strove to discover the source of hemorrhage, succeeding only in finding some
two or three small arteries, which I ligatured, but without materially, if at all,
lessening the flow of blood.

" Finding that the man was gradually getting weaker, and that by compressing
the common carotid artery the hemorrhage was completely stopped, I deter-
mined to tie that vessel.

" I had previously made up my mind that, should a case occur where I was
called upon to tie the artery, and should the place of selection be left to my
own choice, I should ligature it in the cellular interval between the two heads
of origin of the sterno- mastoid, as originally proposed by a French surgeon.
Accordingly I did so, and found the procedure very easy, although certainly
some difficulty was occasioned by the deficiency of light, one farthing candle
being all I could procure. I interfered as little as possible with the cellular
sheath of the artery. The artery was tied with a hempen ligature, as T feared
to employ a metallic one, in case, if any accident should occur, it might be
ascribed to its use. I had not at that time so much confidence in metallic
ligatures as, from their constant employment, I have since acquired, or I should
not have hesitated to use a silver wire, as I did some months ago in tying the
popliteal artery, and as I am always in the habit of doing in cases of amputation.
After the artery was tied, the bleeding entirely ceased ; and the wound having
been dressed, the patient fell asleep, and continued sleeping till nearly the middle
of the following day. As a precaution, however, I left my own dresser to remain
in the house.

" The ligature came away on the twenty-first day, the wounds healed up en-
tirely a few days afterwards, and my patient resumed his duties, which were very
light, in two months from the receipt of the injury.

" During the whole time nourishing diet was prescribed, but no wine, spirits,
or malt liquor was allowed.

" The feature in this operation to which I would especially draw the attention
of the society is the position where the common carotid was tied — a position
which I think presents the following advantages over the situations where it is
usually ligatured : —

" 1. The superficial position of the artery, enabling the surgeon to come directly
upon it.

" 2. The muscles, not requiring to be turned aside, are in no way disturbed.
Though this makes little difference at the time of the operation, it subsequently
aids the free escape of pus.

" I am aware that an objection may be raised on account of the position of
the jugular vein; but it must be remembered that in the above case, in con-
sequence of the previous loss of blood, the size of that vessel was very much
diminished, and it therefore was not calculated to occasion that amount of in-
convenience which it otherwise might have done. During the operation I never
saw it; and had it been troublesome, it would have been very easy to have
restrained its swelling by means of the fingers of the left hand, according to the

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Progress of the Medical Sciences. [July

procedure reeoinmended in tying the common carotid artery." — Edinh. Med.
Journ., January, 1862.

42. Operations for the Cure of Varicocele and Varicose Veins. — Dr. M. H.
CoLLis, in an interesting "retrospect of the progress of surgery during the last
decade," makes the following remarks on this subject : —

" Operations for the cure of varicocele and varicose veins are at present in
great repute in France and England. The simplest and least dangerous of
these are Vidal de Oasis', Lee's, Erichsen's, Startin's, Eicord's, and Tufnell's
methods.

" Yidal inserts a pin behind the veins, and a wire in front of them, but through
the same apertures in the skin ; the wire is passed through holes in either end
of the pin, and the two being twisted, the veins are compressed and gradually
cut through.

"Lee' passes two needles under the veins, and applies the twisted suture for
a few days, until the vein is filled with a coagulum between the sutures ; he then
divides the vein subcutaneously.

" Erichsen^ substitutes, for Yidal's bar and wire, a simple loop of wire, which
he gradually twists until it cuts its way out.

" Startin^ uses what he terms a bar-needle and clasp, which are convenient for
many operations besides those on varicose veins. The bar-needle has a straight
shaft and a curved extremity ; the latter enables the operator to pass it readily
under the vein, the former enables it to compress the vein when passed through.
The clamp is a piece of wire with a loop at either end, which acts as the thread
in the figure of eight suture.

"Ricord makes use of two loops of hempen thread which are passed in oppo-
site directions — one over and the other under the veins ; the ends of each ligature
are then passed through the loop of the other ligature, and drawn tight.

"Mr. Redfern Davies^ and Mr. TufnelP substitute wire loops for thread ; and
the latter surgeon adds what he calls 'retracting guides.' These are simply
threads of wire which are attached to each loop, and which enable the surgeon
to lessen his compression of the vein whenever he pleases, or to remove the
ligature entirely.

" Mr. Davies found it impossible to remove the wire ligatures, in one instance,
and was obliged to cut them close off, and leave them in the man's scrotum,
where they appear to have permanently remained without the patient being
incommoded by, or even conscious of, their presence.

"All these modifications of metallic ligature are preferable to incision, exci-
sion, or caustic, though none of them are free from danger. In operations on
varicose veins in the leg, it is advisable to place a pad on the vein above and
below the point operated on, so that blood may not lodge there. There is no
greater cause of troublesome and dangerous phlebitis than the presence of coagula
in the veins. The danger may be reduced materially by the use of compresses ;
but in no case can operations on veins be considered other than uncertain and
dangerous. In varicocele the use of elastic compresses and suspensories, cold
douching early and late, and abstinence from the general exciting cause will cure
many bad cases, and that with a surprising rapidity. The use of bromide of
potassium (if it can be obtained pure) as an antaphrodisiac, in combination with
iron, if necessary, is a useful adjunct ; and everything should be tried before
risking the patient's life by operation.

" If the mortality were not more than one per cent, we should not be justified
in letting our patient run even that small risk until all other means had failed.
In varicose veins of the leg, the most perfect obliteration will not always cure
the ulcers which have called for the operation ; and if we knew but all relapses
will be found to occur after ligature of the spermatic veins, not to speak of the

' Medical Times and Gazette, January, 1853, &c.

' British Medical Journal, February, 1860.

^ Medical Times and Gazette, May, 1860.

« Lancet, .July 20, 1861.

* Dublin Quarterly Journal, November, 1861.

1862.J

Surgery.

247

possible atrophy of the testis, for whicli our patient would not thank us. For
the leg. a broad band of vulcanized India rubber tightly encircling the limb
below the knee, as recommended by Professor Hargrave, will sometimes eflPectu-
ally compress the superficial veins, and drive the blood into the deeper channels,
especially in thin subjects, and the plan is unattended with risk, and may fairly
claim a trial." — Dublin Quarterly Journ. Med, Sc., May, 1861.

43. Stability of tJie Cure of Varices. — M. Blot communicated to the Society of
Surgery two cases of the spontaneous cure of large varices occurring in pregnant
women. They were seven months advanced, and although the tumours formed
by the veins were large, hard, and red, these entirely disappeared by means of
mere rest, cataplasms, and the use of an inclined plane. They returned neither
before nor after delivery. M. Chassaignac doubted the propriety of the term
radical cure applied to these cases by M. Blot ; for how often do we find the
blood resuming its course in veins which had been temporarily obliterated by
inflammation. The coagula produced by coagulating substances do not either
assure a definitive cure of varices, as they always become absorbed. M. Chas-
saignac is even sceptical with respect to the radical cure of hydrocele by means
of irritating injections ; for he has found the fluid reproduced in the tunica
vaginalis, although this at first had been completely obliterated, and had abun-
dantly suppurated. M. Yelpeau declares that relapse after the operation for
hydrocele did not take place oftener than in four per cent., whether there had
been obliteration of the tunic a-vaginalis or not, such obliteration, especially
definitive, being, indeed, very rare. With respect to the radical cure of varices
he is more disposed to agree with M. Chassaigaac, inasmuch as the obliteration
of the veins, whether produced by the perchloride of iron, caustics, or ligature,
and which is often so difiicult to effect, is not after all durable. The varices are
reproduced. Such reproduction may take place even after excision of the vari-
cose veins ; for M. Yelpeau has seen the saphena vein reproduced ten years
after such an operation. This M. Broca regards as an illusion on the part of
M. Yelpeau. for, as M. Yerneuil has shown, in the great majority of cases, this
large vein which is taken for the saphena is not that vein, but a varicose colla-
teral, taking the same direction as the saphena. With respect to the stability
of the obliteration of the veins, we should distinguish whether this has been
produced by means of coagula or by adhesion of the walls of the vein. Coagula
will disappear at last, even those which have been produced by means of an in-
jection of the perchloride ; and in one case M. Broca has known this to take
place at the end of five years. But when the obliteration is due to the adhesion
of the walls of the vessel, such adhesion is as solid, or even more so, than that
■which takes place between the pleurae. M. Depaul does not regard a relapse as
always a proof that a radical cure has not taken place. A man fractures his leg
at the seat of a well-formed callus, but surely we should not deny that the ori-
ginal fracture had been completely -cured. With respect to M. Blot's two cases.

■ although they certainly are examples in which the varices were cured prior to
delivery, they would have been of more value as examples of radical cure had
they not occurred in the persons of pregnant women, in whom varices habitually
disappear at the termination of pregnancy. M. Depaul added the observation
that the production of varices in pregnant women is not solely due to a mechan-
ical cause, for these varices sometimes appear long before the uterus has attained
a size sufficient to compress the pelvic vessels. There is therefore also some
special cause, the nature of which is as yet unknown. — Gazette Hebdomadaire
de Med. et de Chirurg., 18 April, 1862.

44. True Anchylosis of the Left Hip- Joint, from Rheumatism ; the limb at
a right angle to the body, and abducted ; excision of a vjedge-shaped piece of
the femur; cure. — Dr. H. AY. Berend, of Berlin, recently (21 April, 1862)
communicated to the Academy of Sciences, through M. Yelpeau. a case of
this. The condition of the patient was such as to render impossible the usual
orthopedic method of treatment. Myotomy would have been useless, and violent
extension would have subjected the patient to the danger of a serious fracture

248

Progress of the Medical Sciences.

[July

of the pelvis. M. B. therefore determined to perform Barton's operation, which
he did as follows : —

The patient having been pnt under the influence of chloroform, was laid
on his right side. An incision down to the bone was then made three inches
long, commencing a little above the great trochanter, and extending trans-
versely and outwardly, regarding the anomalous position of the limb, it being
in a state of abduction and flexed to a right angle. The bone was then
denuded and divided by a Charriere's saw and the knife saw, which Dr. B. pre-
fers to the chain saw on account of the difficulty of inserting this last between
the bone and the soft parts. A cuneiform portion of bone was removed, the
base of which was three-quarters of an inch. No hemorrhage followed the
operation. The wound was united by silk and silver ligatures ; and compressing
bandages were applied to prevent hemorrhage.

During the first six days the patient had moderate fever, and he was kept
upon an antiphlogistic diet. On the sixth day the ligatures were withdrawn.
After this nothing remarkable occurred except frequently recurring erysipelas
of the thigh operated on. dependent upon proiracted fetid suppuration from the
bottom of the wound. This was successfully treated by the prolonged use of
cataplasms and a small incision at the anterior portion of the thigh. "

Nine months after the operation Dr. B. commenced certain gymnastic move-
ments, with a view of maintaining the mobility of the false articulation, and at
the same time to strengthen the limb.

Eleven months after the operation the patient was entirely cured, and was
exhibited to many societies of Berlin. The deformity had disappeared, and the
patient could take the longest walk without any other support than a small
stick and without limping. — Gazette Hehdomadaire, May 2, 1862.

This operation, first performed by Dr. J. Ehea Barton, of Philadelphia, has
since been practised by the late Dr. J. Kearney Rogers, of Xew York, and also
by Maisonneuve in France, by Ross in Holstein, by Textor and Waller in Ger-
many, and now by Berend.

45. Dislocation of the TJlna forwards, witlioid Fracture of the Olecranon. —
It has generally been supposed that dislocation of the ulna forwards cannot take
place without fracture of the olecranon. This idea, however, it is observed by
the editor of the article "Dislocation," in the new edition of Coopefs Surgical
Dictionary, "is doubly incorrect; inasmuch as there are at least six well
authenticated cases of the dislocation loithout the fracture, and only three pub-
lished cases in which the two were combined." To the cases of dislocation
without fracture of the olecranon must be added a case related before the Societe
de Chirurgie in Paris on July 31st.

On April 19th. a lad, aged 15, had his arm and hand caught in a mill. The
hand was slightly lacerated; the forearm was broken at the middle ; there was
not much swelling of the cIIdow, and a luxation forwards was readily detected.
The back part of the elbow was flattened ; the processes of the lower end of the
humerus, especially the epitrochlea. projected considerably; the forearm was
half bent, and could be extended and flexed, but with great pain ; the olecranon
could be distinctly felt in front of the elbow. M. Caussin, in whose care the
case was, attempted to reduce the dislocation by extension. Failing in this, on
account (as he supposed) of the shortness of the leverage which was left in
consequence of the fracture, he forcibly flexed the elbow over the arm of an
assistant, and soon reduced the luxation. The patient was able to resume his
work in forty days. — Brit. Med. Journ., Nov. 30, 1861. from L' Union Medicate,
Sept. 7, 1861.

46. Dislocation of the Foot Foriuards. — Dr. De.marquay relates {Moju'teur
des Sciences 2Ud. et Fharm., Oct. 1, 1861) a case of this rare accident. The
patient fell from the last round but one of a ladder which he was descending, in
such a way that the left heel was fixed at the edge of a piece of wood, and the
leg inclined backwards. To save himself from falling backwards, he caught a
piece of wood with his right hand, and supported himself with the right foot.
The left astragalus was driven forwards from its articulation with the tibia and

1862.]

Surgery.

249

fibula. When M. Demarqnay saw him, eight hours after the acciclent, he found
the upper surface of the astragalus forming a projection in front ; the foot was
rotated on its antero-posterior axis, so that the sole looked inwards, the external
border rested on the bed. and the inner edge was directed upwards. The tibia
touched the tendo-Achillis. the projection of which had disappeared ; the mal-
leoli were displaced backwards; there was no fracture of the fibula; and the
tendon of the peroneus brevis projected at the outer side. After having given
chloroform so as to produce complete muscular relaxation. M. Demarquay drew
the heel backwards, at the same time bending the foot on the leg, which was held
fixed. This manoeuvre had to be performed several times before reduction could
be effected. A moderately tight "bandage was applied, and kept moist with cold
water. No symptoms of any importance occurred ; the tumefaction gradually
diminished; and the patient recovered, with perfect use of the limb.

47. Fracture of a Rib produced hy a Sneeze. — Dr. D. F. Castella, of Fri-
bourg. relates the following example of this : —

A keeper of a public-house, thirty-nine years of age. has a robust constitution,
although he has suffered during his life from various maladies, apparently of a
strumous nature. On the 6th November, 1861. he was seated in his bar with
several customers, one of whom offered him a pinch of snuff, which he accepted.
Not being in the habit of snuffing, he was at once seized with a fit of sneezinr.
which he attempted to restrain by shutting the mouth and forcibly dilating the
chest. In this, however, he failed, and a violent expiration having succeeded to
the excessive and prolonged dilatation of the thorax, he felt at the same moment
in the left hypochondriac region a sudden, sharp pain, accompanied by a very
distinct crack, difficulty of respiration, and a very painful cough. I was at once
summoned.

I discovered in the middle of the body of the ninth rib on the left side a very
evident crepitation, and an oblique solution of continuity. It was then a frac-
ture of the second false rib on the left side. I was able to confirm this diagnosis,
as the same symptom persisted during four or five days, with slight tumefaction
of the surrounding soft parts. No complication in the part of the pleura or
lung supervened.

I am not aware that violent sneezing has been cited by authors as a cause of
fracture of the rib. If this case is not unique, the fact must have been but
rarely observed. It is interesting in a surgical point of view, and it is important
in legal medicine to know that rapid and strong contraction of the diaphragm,
preceded by an excessive and prolonged extension of that muscle, may occasion
the fi-acture of a rib. — Glasgow Medical Journal, April, 1862, from Gazette des
Hopitaux.

48. Transverse Fracture of the Patella. — ^Ir. Holthouse showed to the Pa-
thological Society of London a specimen of this, in which the fragments were
two inches and a half apart, but united by true ligamentous tissue. He observed
that in 18.i0, Mr. William Adams directed the attention of the Society to a
mode of connection of the fragments of a patella fractured transversely that had
not, up to that time, been recognized. He demonstrated that certain cases
which were usually regarded as examples of true ligamentous union in which
the ligament had become elongated, were in reality cases of non-union, the con-
necting material being no new structure interposed between and uniting together
the fractured surfaces, but simply the fascia which passes over the patella in a
thickened condition, and having incorporated with it the bursa patella. In
true hgamentous union the separation of the fragments is generally from half an
inch to an inch, and Mr. Adams had not seen it exceed one inch and a half."
The specimen exhibited was removed from a patient of Mr. Holthouse, who
died in the Westminster Hospital ; but as the lesion was not observed till after
death, no history of it could be obtained. A longitudinal section through the
two fragments and their connecting mediums, showed the latter to consist of
true ligament, two inches and a half in length, uniting the fractured surface of
one fragment to that of the other, and inclosed between the fibrous capsule of

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[July

the joint on the outside, and the synovial membrane on the inside. The ligament
was strong and thick at its attached extremities, but became somewhat thinner
towards its centre. Mr. Holthouse observed that he considered the specimen
worthy of exhibition on three grounds : 1st. Because it showed that a separation
of the fragments of a broken patella to the above extent is not necessarily a
proof of non-ligamentous union. 2d. Because it illustrated the extent to which
the new material may become elongated ; for he supposed it would not be dis-
puted that at one period the fragments must have been, if not in actual contact,
at least in much closer apposition than at present, or no new uniting material
would have been thrown out ; and 3d. Because it demonstrated the importance
of not using the limb till the uniting medium had become sufficiently firm to
resist the action of the muscles which flex and extend the leg. — Med. Times and
Gaz., March 15, 1862.

49. Statistics of Amputations at the Hospitals of Paris. — Dr. Ulysses Trelat
communicated to the Academy of Medicine of France (March 25, 1862) the sta-
tistical results of the greater amputations in the Parisian hospitals. These sta-
tistics embrace the following hospitals : Hotel-Dieu, from 1850 to 1861 inclusive,
11 years ; Piti6, from 1851 to 1861, 10 years ; Charity, from 1850 to 1861, 11
years ; Saint Antoine, from 1853 to 1861, 9 years; Necker, fronj 1848 to 1861,
U: years ; Beaujon, from 1850 to 1861, 11 years ; Laribosiere, from 1854 to 1861,
8 years; I'Hopital des Cliniques, from 1855 to 1861, 7 years; I'Hopital des En-
fants Malades, from 1851 to 1861, 10 years ; Sainte Eugenie, from 1854 to 1861,
8 years — in all, 99 years, almost a century of hospital practice.

Excluding some exceptional cases which are pointed out and disregarded,
there were 1144 amputations, as follows: At the hip-joint, 3; thigh, 360; at
the knee-joint, 4 ; leg, 418; foot, 116 ; shoulder-joint, 27 ; arm, 141 ; elbow-joint,
4; forearm, 44; hand, 27.

Of the whole number, death resulted in 522, or in 45.6 per cent.

Pathological amputations, 568 ; deaths 223, or 41 per cent.

Traumatic amputations, 470 ; deaths 261, or 55.5 per cent.

Amputations from undetermined causes, 28 deaths, or 26 per cent. The
smallness of this mortality results from there being included in this category a
proportionably great numlDer of children.

The mortality among males was 438 in 908 operations, or 48.2 per cent.;
among females, 84 in 236 amputations, or 35.5 per cent. M. Trelat explains
this difference, 1, by the relative fewness of operations and of severe wounds in
the female wards.

As to age, that which furnishes the smallest mortality is that from 5 to 15
years, viz., 18.9 per cent., or 15.2 in the pathological amputations, and 16.6 in
the traumatic. The mortality previous to the fifth year of life is nearly the same
as that between the ages of 15 and 30 ; after the 15th year it increases regularly
and without interruption, whatever may be the nature of the amputation or the
sex of the patient. Beyond 70 years of age it becomes so large as 95 per cent.,
that is, one only recovers of twenty operated on ; hence M. T. reprobates am-
putation in those above 70 years of age. — Gazette Hehdomadaire de Med. et de
Chirurg., March 28, 1862.

50. Perforating Gunshot Wound through the Thickness of the Lung ; Reco-
very.— Dr. Wood's, R. N., records the following remarkable case : —

Private E., Royal Marine Infantry, whilst serving in the Burmese campaign,
was struck by a musket-bullet two inches below the right nipple. The projectile
passed back and out through the thorax, between the fourth and fifth ribs near
their angle, posteriorly, whence, being unable to perforate the elastic skin, it
passed round horizontally to the median line, and lay upon the spine beneath
the integument and facia.

I forthwith turned the man over on his face, and cut down upon the bullet
with a fair crucial incision. And here, I may observe, that no sugeon in the
field fcJhould underrate the importance of extracting even a superficial bullet
under such circumstances, especially if it be contiguous to a cavity, unless he
has a tenaculum forceps to grasp it with : for if possible the elastic " cyst," as

1862.]

Surgery.

251

it were of fascia, enveloping the bullet, will jerk it back into its trajet, unless
the incision be very free, and the grasp of the ball tenacious, whilst the patient
and his comrades regard with the greatest anxiety the successful extraction of
the bullet. And no subsequent time like the moment of being stricken, whilst
the faculties are all engaged elsewhere, will the surgeon find equally desirable
for operation or extraction. In this instance, I fixed the bullet against the
underlying spine, and thus extracted it with facility. Florid arterial blood
spurted from the wounds at each inspiration and expiration, and the same,
mixed up with air-bubbles, was thrown out by the mouth in frequent short
coughs. The pulse was at 130, small and fluttering ; the surface was clammy
and cold ; and the anxiety of countenance such as one only sees in the course
of gunshot wounds of vital organs. His mouth being parched, and utterance
nil, I poured down his throat a draught of rum and water from my canteen ; and
observing a portion of his shirt deficient, where the bullet had sped, I passed a
long steel ball-probe through the wound, into the lung, which was marvellously
insensible to the touch, but could thus discover no foreign body.

I next applied a roller so as to fix the ribs as far as possible, leaving the
wounds free, and I dressed the apertures but lightly with lint, so that the blood
might flow externally, rather than that unnecessary effusion should occur within
the pleural cavity.

This, I am aware, is a moot point in military surgery, whether, if hemorrhage
must occur from a wounded lung, it were better to be internal, so as to make
pressure within the pleura on the lung ? or whether the surgeon in the field had
better, by all means in his power, induce the arterial hemorrhage to flow exter-
nally instead, if flow it must? The former object I, in this case, had some
intention of trying to favour, by fixing the ribs on that side with a thin coating
of plaster of Paris applied over a piece of lint, moistened with gum-water, and
allowed to " set" upon the ribs, as a light "mould," in fact, trusting afterwards
to absorption of the effused blood. However, the man's anxious expression
caught my eye, and I concluded I had better follow the beaten track whilst his
life hung thus upon a thread, rather than innovate, however plausibly, shut off
as I was from consultation by several hundred miles of space. Would any
member or members of the Surgical Society grant the favour of an opinion on
this subject? Much arterial hemorrhage from the shot wounds, and through
the mouth, occurred at intervals for twelve hours, during which I kept the man
in the sitting or semi-recumbent posture. Acetate of lead and opium were
given every second hour in pill, and he used a solution of tartarized antimony
every half hour, which with fresh tonics and cold acidulated drinks, constituted
his treatment thus far. The hemorrhage then ceased, and I had no recurrence
of it.

On the third day his tongue was thickly coated ; urine scanty and high-
coloured ; pulse, which previously had fallen to 100, now 130. Continuing the
antimonial, I gave him a calomel and nitre purge, when his pulse again fell to
near 100 ; tongue cleaner.

On examining his chest there was dulness for a palms' breadth around the
wound of entry, and the same near the angles of the ribs, where the bullet left
the thorax, with external discolouration. The respiratory murmur was absent
in the same situation, and there were bloody rales throughout the entire lung.
He had a short hacking cough and hurried constrained respiration, with dilated
nostril, and a painfully anxious countenance, especially when the bandage was
temporarily removed. On the fourth day he was breathing better ; countenance
was less anxious ; pulse was at 90 ; evacuations were natural : there was slight
dry cough, and both wounds were suppurating kindly. Percussion and auscul-
tation gave the same results as before, I now gave him a blue pill morning
and evening, and a few fowls were foraged out for broth. In a few days, the
gums being slightly touched with the mercurial, and all active treatment stop-
ped, I was enabled to remove him to the hospital ship, several days' journey
distant, where I continued in charge of him.

The wounds suppurated freely for a month, and then, for the first time at the
posterior orifice, appeared in the discharge a strip of his shirt, which being car-
ried in by the bullet, traversed the lung from front to rear. I had him in my

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Progress of the Medical Sciences. [July

charge for a fortnight after, at which time the anterior wound (of entry) was
completely healed ; the posterior one very nearly so. I applied a mixture of
iodine and mercurial ointment as a discutient, in the neighbourhood of the hepa-
tized lung, for several days, by which I think the obstruction was in some mea-
sure removed, and the constriction and sense of pain through the chest alleviated.
The man was now able to walk about ; general health tolerably good. There
was a slight hitch remaining in the respiration, some pain of right side, and his
chest was somewhat hollowed from absorption of tissue in the neighbourhood of
the bullet track. There was some slight bulging of the intercostals at the lower
part of the pleura, and dulness corresponding to it, but no evidence of fluid from
succussion. Pulse was 80 ; countenance, " shot-stricken."

The man was no doubt ultimately discharged from the service, as unfitted to
bear the vicissitudes of a " sea soldier's life," but I dare say able all the while
to supplementalize his means of living and his pension by any light employment
in civil life. This case is interesting, inasmuch as I see that perforating gunshot
wounds, through the thickness of the lung, are in most instances recorded as
fatal. — Diiblin Medical Press, April 9, 1862.

51. Difficulties in the Treatment of Uinbilical Hernia. — M. Huguier, in a
discussion in the Surgical Society of Paris, gave a summary of the. causes which,
in his opinion, render strangulated umbilical hernia and the operation thereon
specially dangerous. Some of these causes are primary — arising out of the
anatomy and pathology of the parts ; the others are surgical — attending and
following the operation. The primary causes are the following : 1. The abdo-
minal opening, in general circular or oval, narrow, resistant, and with thin edges,
bruises and almost cuts the parts. 2. The umlDelliform or mushroom-shaped
arrangement of the protruded parts gives the tumour a narrow pedicle in pro-
portion to the mass which has escaped. 3. The thinness of the coverings pre-
disposes to accidents in three ways — by bruising of the parts ; by inflammation
of the distended and weakened coverings ; and, perhaps (as in an example re-
lated by Boyer), by their rupture through a fall or blow. Further, this state
of the integuments render the intestines liable to injury during operation. 4.
The sac contains little or no serosity. 5. The sac is frequently gangrenous. 6.
The large size of the tumour, and the adhesions which it contracts, render it
more frequently irreducible. 7. The vicinity of the strangulation to the perito-
neal cavity predisposes to visceral and parietal peritonitis ; this circumstance is
of great importance in a surgical point of view. The surgical or consecutive
causes of peril are these : 1. In the flrst stage of the operation, there is great
danger of wounding the herniated parts, in consequence of the thinness of the
coverings, the frequent absence of fluid from the sac, and the presence of numer-
ous adhesions of the viscera to each other and to the peritoneum. 2. In the
majority of cases, it is necessary to reach the intestines, to pass through the epi-
ploon; which, after being wounded, is returned into the abdomen. 3. The her-
niated parts may suddenly burst through the incision in the covering. Boyer
and M. Huguier have both met with instances of this, 4. After the parts are
denuded and liberated from strangulation it is extremely diflicult, sometimes
even impossible, to reduce the hernia. 5. The proximity of the incision made
in releasing the strangulation to the parietal peritoneum necessarily causes this
to be wounded. In inguinal and crural hernia, the strangulation is at a distance
from the great peritoneal cavity ; whereas the reverse is the case in umbilical
hernia. 6. Extension of inflammation from the sac to the peritoneum is more
rapid and much more unavoidable than in other hernise. 7. The dependent
position of the hernial opening, when released from strangulation and enlarged,
favours (as M. Yelpeau has observed) the escape of blood, pus, and decomposed
fluids into the peritoneum. M. Huguier says that blood is by no means innocu-
ous ; he has seen violent peritonitis produced by the presence of a small quan-
tity in the cavity. If an operation is to be performed, he advises that complete
herniotomy (incision of the coverings, release of the strangulated parts, and
reduction) be practised only in small, recent umbilical herniae, which have been
previously reducible. In most other cases, he prefers opening the intestine to

1862.]

Surgery.

253

releasing, tlie strangulation and reducing the parts. — Brit. Med. Journ., Jan. 25,
1862, from Gaz. des Hopitaux, Nov. 23, 1861.

52. JEther and Belladonna in Strangulated Hernia. — Dr. Burkhardt states
that for many years past he has employed for the reduction of strangulated
hernia, in conjunction with the taxis, a mixture of one ounce of ether and two
drachms of tincture of belladonna, which is either dropped upon the hernial
tumour or applied to it as a lotion. He has seldom found it fail even in cases
in which the strangulation has long existed. The benefit which results is not a
consequence of the mere cold produced, which may easily be induced, and in a
much greater degree, by other means, without the same effect being produced. —
Med. Times and Gaz., April 19, from Varges' Zeitschrift, vol. xv. No. 1.

53. Camphorated Cfiloroform as a Local Ancesthetic in Extirpation of the
Toe Nail. — M. Martenot de Cordoux relates [Bulletin de la SociSte de M6de-
dne de Besangon) two cases of removal of toe nail, in which pain was entirely
prevented by the following procedure : —

The toe was in the first place tightly surrounded at its basis with a ligature,
and enveloped for twenty minutes in a thick layer of lint impregnated with cam-
phorated chloroform, and to obviate evaporation, a water-proof cloth was laid
over all. The fluid used consisted of a solution of four drachms of camphor in
one ounce of chloroform.

M. Martenot de Cordoux removed at one sweep of the knife, by Mr. Bauden's
operation, one-half of the nail and the exuberant flesh ; and although in one case
this procedure had to be twice repeated, the anaesthesia was so complete that
no pain whatever was experienced. — Glasgow Medical Journcd, April, 1862.

54. Congenital Inversion of the Bladder ; Cure. By J. Lowe, M. D. — This
affection is so rare that it is passed over in silence by most authors of systematic
works on surgery. The only recorded case which I have met with is that given
by Mr. Crosse, in the British and Foreign Medical Review (Oct. 1846, p. 319),'
which is exceedingly interesting as showing the importance of careful diagnosis
before attempting any operative measures on tumours of the genital parts in
female children. In this instance, the patient, aged three years, had a tumour,
to which a surgeon was about to apply a ligature, when Mr, Crosse, who hap-
pened to be present, fortunately discovered an aperture which he found to be
the ureter. The operation was of course postponed sine die. By firm pressure
the inverted bladder was made to repass into its natural position, and conse-
quently the child was saved from an untimely death. The report goes on to
say that the prolapse of the bladder did not subsequently return ; and the
patient grew up to womanhood with no other inconvenience than a constant
incontinence of urine. .

The following report of a very similar case may prove worthy of being re-
corded, more especially as operative interference, which does not appear to
have been found necessary in Mr. Crosse's case, was here pursued with excellent
results : —

M. A. H , aged two years and a half, a fine, healthy, but very irritable

girl, was admitted into the West Norfolk and Lynn Hospital on the 10th of
November, 1859. On examination, a vascular-looking tumour, about the size
of a large Italian walnut, was found projecting between the external labia. When
the little patient cried, the tumour became more injected, and increased con-
siderably in size ; at the same time, a gush of urine took place. On closer in-
spection, the mass was found to be seated at the orifice of the urethra. On
making a little gentle pressure, the tumour receded under the finger, and pre-
sently disappeared altogether within the urethra, and the forefinger could be
readily passed into the bladder. I had, therefore, no difficulty in diagnosing an
inversion of the bladder.

From the statement of the mother, it appeared that the child had been subject

' From the Transactions of the Provincial Medical and Surgical Association, vol.
xi., 1846.

254

Progress of the Medical Sciences.

[July

to incontinence of urine from its birth, and that from the time it was two or three
days old, a small substance had been observed to protrude during a fit of crying
or straining. Each effort of this kind was followed by a flow of urine, and the
child's condition from this cause was truly pitiable. The thighs and labia were
much excoriated, and the latter, as well as being swollen and indurated, were
covered with numerous pustules. Until the age of two years, the tumour had
receded as soon as the fit of straining was over ; but latterly it constantly pro-
truded more or less.

After considering the various means which might afford a chance of improving
this distressing condition, I resolved upon making use of the actual cautery,
which seemed to me best adapted for narrowing the calibre of the urethra, and
thus preventing the descent of the bladder. Accordingly, after putting the
patient under the influence of chloroform, and having replaced "the bladder
within the pelvis, where it was retained by two stout probes, which served to
keep the canal patent, a female sound, heated to a white heat, was applied to
the track of the urethra. A small curved catheter with a bulbous extremity,
which had been previously made by my direction, was then introduced and fast-
ened in, and the patient put to bed. No constitutional symptoms followed, but
there was considerable pain in passing urine.

On the 17th, a small shred of slough separated. Patient can retain four ounces
of urine when in the recumbent posture.

Pec. 1st. The catheter on being removed was found coated with a thick de-
posit of phosphate of lime ; urethral canal perceptibly smaller.

After the expiration of a month, during which time there was destination
pretty constantly, with occasional power of retaining several ounces of urine,
the cautery was again applied as before. The same manifest improvement fol-
lowed. The child became much more comfortable and cleanly in person. The
excoriations almost entirely disappeared, and the pustules healed.

On three subsequent occasions (making five in all) the cautery was repeated
after long intervals. The urethra became so much diminished as to admit only
a No. 4 catheter ; urine escaped only when patient cried or strained.

After having been a patient of the hospital about eleven months, during the
latter part of which she was an out-patient, coming in at intervals to be operated
on, she was discharged. I have since learned that she continues well, with not
the slightest evidence of prolapse, but with some degree of incontinence of urine.
—Lancet, March 8, 1862.

55. Tlie Cochin China Ulcer. — M. Pochard, Chirurgien-en Chef of the French
Navy, describes a form of ulcer which is endemic in certain parts of Cochin
China, and has prevailed extensively among the French troops in that country.
Its predisposing causes are the insalubrity of the climate, and the consequent
anaemia and debility. It is more severe during the rainy season ; age, constitu-
tion, and race, have no influence on its production. The characters of the ulcer
are aggravated among the natives by dirt, skin-diseases, weak constitution, and
the want of treatment. There is no evidence to prove that it is contagious ; but
rather the contrary.

The ulcer always commences with a lesion of the skin, never suddenly ; but,
in debilitated subjects, the most insignificant wound or erosion is sufficient to
produce it. The lower limbs are always its seat ; it especially attacks the
ankles, the anterior part of the lower third of the leg, the instep, and the dorsal
surface of the foot. M. Pochard has never known it to appear on the plantar
surface. It is generally solitary, but sometimes both legs are affected at the
same time. The diameter of the ulcer is rarely less than nearly two inches ; but
sometimes it extends round the legs, and in some very rare cases the whole leg
has been involved. The form of the ulcer is irregularly angular. The ravages
of the disease are generally confined to the skin and subcutaneous tissue : in
severe cases, however, it burrows among the muscles, and produces exfoliation
and necrosis or caries of the tendons and bones. In this condition, amputation
is the only resource, but is rarely successful.

The progress of the disease is rapid. Under the influence of the predisposing
causes already mentioned, an apparently insignificant lesion b'ecomes painful ; it

1862.]

Ophtlialmology.

255

is surrounded with a dark red areola, and in a few days there is a large ulcer of
gangrenous aspect, from which escapes an extremely fetid ichor. The inflam-
matory period is accompanied by pains which contrast strongly with the com-
plete insensibility which prevails at a later period.

After a variable time, the ulcer ceases to increase ; it becomes clean ; an.
eschar, comprising generally the entire thickness of the skin, is detached, leaving
a sanious surface, which is soon again covered by a pultaceous layer. In the
most severe cases, the disease runs its course, increasing in surface as well as in
depth; and finally produces death, unless amputation be performed. In the
more favourable cases, after numerous alternations of amelioration and of re-
lapses, cicatrization is established; and, if the patient can leave the country and
regain his strength, the cure is permanent. In other cases, again, the disease
becomes chronic ; and it is in this form alone that M. Rochard has had personal
opportunities of observing its character. In the patients under his care at the
Brest Hospital, the ulcers presented a depressed, uneven base, traversed by
deep red longitudinal streaks, consisting of small anastomosing bloodvessels,
having between them yellowish lines of a pultaceous aspect. The edges of the
ulcer are callous, as if cut perpendicularly, but irregular; the surrounding skin
is wrinkled, the folds radiating towards the centre of the ulcer. There is com-
plete anaesthesia, not only in the parts immediately affected, but also in the sur-
rounding parts, and sometimes even in the whole limb below the ulcer. In one
case, the ulcer was seated below the external ankle ; and both the dorsal and
the plantar surfaces of the foot were insensible ; no sensation was produced by
the application of the strongest caustics or of red hot iron. The subjacent
muscles are also sometimes paralyzed; this happened in the case just mentioned.
No treatment seems successful. Cauterization, with tonics and good diet, have
appeared at first to produce the most promising results : but as a rule, the dis-
ease returns as soon as the patient begins to walk. In one case, where the ulcer
was seated on the dorsum of the foot, M, Rochard obtained a successful result
by excising the ulcer, and performing partial excision of the foot. — Dublin Med.
Press, May 21, 1862, from Gaz. des Hop.

OPHTHALMOLOGY.

56. Frequent Evacuation of the Aqueous Humour as a, Means of Causing
tTie Absorption of Cataract, — Prof. Sperino, of Turin, recommends the repeated
evacuation of the aqueous humour for the purpose of causing the absorption of
opacities of the crystalline lens, and asserts that it has proved successful in
various cases under his care at the hospital at Turin. He remarks, "The prac-
tical studies I have been continuing for several years on the new method of
treatment in various disorders of the ocular bulb, have induced me to have
recourse to it also in the case of persons labouring under cataract. The facts
observed by me up to this day at the Ophthalmic Hospital, at the House of
Public Assistance, and within the range of my own private practice, have proved
to me that the evacuation of the aqueous humour effected daily, or even every
second or third day, will gradually restore transparency to the crystalline lens,
and consequently remove the obstacle which impedes vision. It is curious to
observe how the opaque materials of the crystalline lens are gradually replaced
by transparent ones, owing to the frequent removal of the aqueous humour, and
it is not less consolatory to hear the patients daily congratulate themselves on
the gradual recovery of their eyesight. At present I merely announce my dis-
covery, but I shall soon publish my clinical observations, which are daily increas-
ing in number, and I shall then describe the experiments by which I have been
guided, the method of cure, its effects in the various kinds of cataract, and dif-
ferent degrees of opacity of the crystalline lens ; in a word, all I daily learn from
the attentive observation of facts. Let me, however, remark, that, supposing in
certain cases the mere evacuation of the aqueous humour were not found siiffi-

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Progress of the Medical Sciences.

[July

cient to obtain a perfect cure, this observation would still have the effect of
restoring the functions of the inner vascular system of the eye, and would thus
at all events prepare the patient by placing him in the most favourable condition
for the operation of the cataract."

Dr. J. G. HiLDiGE has experimented with this method, and has given the
results in a recent No. (May 21, 1862) of the Dublin Medical Press.

"Having," says Dr. H., "some misgivings as to whether a frequently repeated
paracentesis of the cornea might not cause a too great irritation of the ocular
bulb, I selected an eye that was not only cataractous but also partially amau-
rotic. The patient, Mrs. 0., aet. 45, residing in Eedmond's-hill, is affected with
soft cataract in both eyes. That in the right eye is perfectly formed ; the inter-
nal portion of the retina is, however, insensible to light, so that when a candle
is held in the external part of the field of vision, at the distance of a few inches
from the eye, it is not perceived ; the other tissues of the eyeball are tolerably
healthy. The vision of the right eye is still good enough to permit her to go
about alone, and to see large objects. General health pretty good. I punctured
the left eye with a broad-bladed needle at the external junction of the cornea
with the sclerotic, and allowed the aqueous humour to escape. On the following
day I repeated the puncture, introducing the needle at the inferior part of the
cornea, and so varying the seat of the puncture each time, as to cause as little
irritation to the eyeball as possible.

"The eye was slightly inflamed on the third day, the pupil contracted, and
other symptoms of irritation present, so that I was obliged to allow two or three
days to intervene before resuming the treatment. It were needless to describe
the effect of each paracentesis on the eyeball ; let it suffice to say that I repeated
the operation eleven times, allowing one. two, and three days to intervene, ac-
cording to the amount of irritation present, and the following was the result of
the treatment : The cornea had become slightly conical, so that the anterior
chamber was much deeper than in the normal condition ; the iris was of a much
deeper tinge than that of the other eye ; pupil contracted, and small dots of pig-
ment, detached in all probability from the posterior part of the iris, were depo-
sited on the anterior capsule of the lens. On dilating the pupil with atropine,
one side of it was observed to be adherent, and masses of pigment were attached
all round its circumference, protruding as it were from the posterior surface of
the iris. The lens was in every respect in precisely the same condition as it was
previous to the commencement of the treatment, presenting the same degree of
opacity without the slightest symptom of absorption having taken place in any
portion of it. The effect of the frequent paracentesis was certainly to produce
hypersecretion of the aqueous humour ; this, however, instead of causing absorp-
tion of the cataract, produced a more or less staphylomatous condition of the
cornea, the anterior chamber not being capacious enough to contain the quantity
of aqueous humour secreted. This result has not justified me in experimenting
on a second case, the eye having been decidedly damaged by the treatment. As
Professor Sperino has, however, promised to publish shortly the notes of his
cases, we shall then be better able to form an opinion of the question than we
are at present."

[Though we are far from hopeful of the success of this mode of treatment of
cataract, it must be confessed that the evacuation of the aqueous humour is likely
to affect the nutrition of the lens, as would also its replacement by injecting
fluids of different densities. The experiments of Drs. Mitchell and Richardson
seem to open a wide field for investigation in regard to this subject.]

57. He:reditary Amaurosis. — Mr. Sedgwick related to the Harveian Society
of London the case of a gentleman whose brother became blind from amaurosis
in both eyes, between the age of 55 and 60 years, had a family of ten children,
consisting of seven sons and three daughters. The first son, who is still living,
became amaurotic in both eyes when about 56 years old ; the fifth son, who died
from paralysis, became amaurotic in both eyes at the age of 48 years ; the sixth
son, still living, became amaurotic in the left eye at the age of 46 years ; and
the seventh son, now dead, became amaurotic in both eyes when about 42 years
old. Of the other three sons, the second, who died from paralysis at the age of

1862.]

Ophthalmology.

257

56 years, the third aged 60 years, who is still living and is partly paralyzed,
and the fourth aged 56 years, also living, have no occurrence of the disease.
"Whilst the three daughters, who are all living — the eldest of whom is now 63
years of age, and is the second child in the family, and the youngest about 38
years of age, who is also the youngest child in the family — have been quite free
from the disease. Mr. Sedgwick remarked that the above case would serve to
illustrate two points of interest in connection with the hereditary development
of disease, viz., the sexual limitation of the disease to the males only in the
family, all the females being exempt, and the retrogressively earlier develop-
ment of it in each succeeding member of the family affected ; so that, whilst
the eldest of the four brothers became amaurotic at about the same age as his
paternal uncle, the three younger became so at an earlier age in each case than
the preceding, the sequence being 56, 48, 46, and 42. — Med. Times and Gaz.,
March 22, 1862.

58. Amaurosis cured hy Evacuation of the Aqueous Humour. — An interesting
case of amaurosis was recently observed in the ophthalmological clinique of the
University of Munich. A country girl, aged 18, while at her work, suddenly
felt that her sight became diminished. All objects appeared to her as in a haze,
and on the next day she was scarcely able to distinguish anything. The day
after she went to church, but had to be carried home, as she had then lost her
sight altogether. Leeches, ice, and purgatives were used, but without success ;
and six days after the vision had first become impaired the patient came to
Munich, and was received into the University Hospital. The pupils were im-
mensely dilated, and did not contract even if very strong light was used. By
means of the ophthalmoscope it was then observed that the arteria centralis
retinfB was unusually narrow, and its ramifications did not contain any blood.
The vein appeared very dark and narrow, but not to the same degree as the
artery ; on slightly pressing the eyeball no pulsation could be felt. The choro-
idea was normal, and its vessels were clearly visible. Otherwise there were no
traces of oligsemia; on the contrary, the complexion was ruddy, the pulse full,
and the sounds of the heart were normal. The patient complained of noises in
the ear, and of heat in the head. At the time when she had become blind, she
had just had her courses, but they had been more scanty and shorter than usual.
The treatment in the hospital consisted of leeches to the temples ; foot-baths,
and sinapisms to the thighs. On the second day, calomel, in refracta dosi, was
added to this medication. On the third day the patient said that if a hand was
passed before her face she could see it with the left eye ; while the right con-
tinued to be completely amaurotic. After nineteen days there was no further
improvement ; on the contrary, the ophthalmoscope showed that the arteria
centralis retinae had become still narrower than it had been at first, and that the
chief branch of the same artery on the right side did not contain any blood. It
was, therefore, feared that the retina might become atrophied in consequence of
anaemia of its vessels ; and paracentesis of the anterior chamber of the right eye
was then performed by the surgeon. Mr. Rothmund, with the view of inducing
congestion by the vacuum thus caused in the eye. Immediately after the opera-
tion the pupil appeared contracted, as is always the case after paracentesis ; but
on the next day the patient was able, with the eye upon which the operation had
been performed, to count the fingers held at a distance of six inches from the
eye ; and on the fourth day after the operation she could see the fingers at a
distance of one foot and a half. The pupil had, by that time, also again become
sensitive to light and dark. As the left eye did not improve in the meantime,
it was operated upon in the same manner. The vision then likewise improved
in this eye, and on the ninth day the patient was again able to read large type.
She was discharged cured, as after some time she could read the very smallest
type, and the ophthalmoscopic examination showed that both retinae were per-
fectly normal. A similar case has been published by Dr. A. Yon Uraefe, who
by excising a piece of the iris of the right, and making the paracentesis of the
anterior chamber of the left eye, also completely cured his patient. — Med. Times
and Gaz., April 12, 1862.

No. LXXXYIL— July 1862. IT

258

Progress of the Medical Sciences. [July

59. Retinitis LeuJccemica. — Dr. Liebretch, one of tLe most distinguished
pupils of Prof. A. Yon Graefe, and of whose researches on retinitis pigmentosa
in the offspring of marriages of consanguinity I gave you an account in a former
letter, has recently discovered that in patients suffering from leukaemia, a pecu-
liar form of retinitis occurs, which has just as characteristic features as that
form of retinitis which is observed in cases of syphilis and Bright's disease.
Idiopathic retinitis is, according to Dr. Liebreich, exceedingly rare, and it is a
curious fact that,, while idiopathic diseases of the choroidea are much more fre-
quent than those due to constitutional distempers, the disorders of the retina
are either of local origin, and consequent upon wounds or diseases of the adja-
cent choroidea, or produced by disturbances of general circulation, as in cases
of heart disease and Bright's disease, and by diseases of the blood, such as
syphilis and leukaemia.

In retinitis consequent upon Bright's disease, the ophthalmoscopic examina-
tion shows that the optic nerve is encircled by an opaque, whitish zone ; between
the nerve and the zone a grayish-looking part of the retina is visible, which is
scarcely to be distinguished from the papilla, which latter has also a grayish
appearance. Outside of the opaque zone just mentioned, small and fine points
may be generally noticed, which are due to extravasation, and are chiefly fre-
quent in the neighbourhood of the macula lutea. In retinitis syphilitica, on the
contrary, the opacity extends from the papilla along the course of the large blood-
vessels, and towards the periphery, where it gradually ceases. Extravasations,
which are very frequent in retinitis coupled with Bright's disease, are exceed-
ingly rare in syphilitic retinitis ; and if present, they are totally different from
those observed in the former affection. In leukgemic retinitis it is especially
the colour of the bloodvessels and of the extravasated blood, which presents
striking peculiarities. The blood and the veins, which are very much dilated,
are of a pale pink ; the arteries are contracted, and of a bright orange colour,
and the vessels of the choroidea of a pale yellow. — lied. Times and Gaz., April
12, 1862.

60. Embolism of the Arteria Centralis Retince. — The chief symptoms of this
disease, of which Dr. Liebreich has hitherto observed six cases, are the follow-
ing : The patient suddenly perceives dimness of vision in one eye, as if a thick
cloud was passing. He then generally closes the other eye, and finds that, after
a few minutes, the whole field becomes so obscured that not even the faintest
perception of light is possible. This condition either remains stationary, or a
slight perception of light gradually returns in a limited part of the field. The
ophthalmoscopic examination of the eye shows that the circulation in all or
several of the arteries of the retina has altogether ceased ; the vessels are thin,
and partly filled with thick and dark coagula. The central artery of the retina
is quite empty, and the veins are also much thinner. A few days after the com-
mencement of the illness, an opacity of part of the papilla, macula lutea, and its
neighbourhood, is visible ; and between the macula and the optic nerve, small
red points are to be perceived, which are owing to extravasated blood. Although
there is no blood in the arteries, the venous circulation is not entirely stopped,
but it is retarded and irregular. After some time, however, this is, in a measure,
re-established ; while the arteries either remain empty, or again contain a little
blood. The opacities in the macula lutea undergo various changes as to colour,
size, etc. ; and, finally, the optic nerve is completely atrophied.

In five out of six cases of this affection there was heart disease. In one case
considerable insufiiciency of the aortic valves, with consecutive hypertrophy and
dilatation of the left ventricle, was found to exist. The compensation afforded
for the valvular disease by the hypertrophied muscular substance of the heart
was so complete that the patient was not even aware of having heart disease,
and which was only discovered by Dr. Liebreich after, by the embolism of the
arteria centralis retinae, he was led to make the physical examination of the
chest. In the same patient, an embolus was soijie time afterwards lodged in the
brain, and produced hemiplegia. — Ibid.

1862.]

Ophthalmology.

259

61. Loss of an Eye from the Bite of a Leech. — Prof. Yox Geaefe relates, in
the second part of the seventli volume of the Archiv fiir Opldlialmologie, the
case of a delicate little girl, of five years of age, who, some days before he saw
her, had on account of headache been ordered a leech to the right temple. The
eye itself before this application had been quite healthy, and its vision perfect.
He found the interior chamber filled with blood ; the lower half of the conjunc-
tival sac, including the edge of the cornea, ecchymosed ; in the lower half of the
cornea, nearly a line from the limbus conjunctivge, a wound, the edges of which
and neighbourhood were somewhat swollen, and presented a grayish opacity.
The form of the wound, on close inspection, left no doubt that it was the result
of the bite of a leech. It came out, that, in making the application ordered, the
leech had slipped away, had crept into the eye, and there, under considerable
pain to the child, had accomplished its work of destruction. Unfortunately,
perception of light was completely lost, apparently in consequence of total sepa-
ration of the retina by hemorrhagy.

As the Professor had never in such a case of haemophthalmos, from whatever
cause arising, observed a restoration of sight when once quantitative perception
of light had for more than some hours been lost, so here he gave the most un-
favourable prognosis. He saw the child a few times afterwards. The blood in
the anterior chamber had partly disappeared, the eyeball was already boggy, and
he had no doubt that phthisis oculi had commenced.

The Professor observes, that the case, while on the one hand it serves as a
warning against the careless application of leeches in the vicinity of the eye, is
interesting in another respect, that the bite was not within the extent of the
conjunctiva, but nearly a line from it, and in a part which in the normal state is
deemed destitute of vessels. How far the leech filled itself with blood, and how
long it sucked, he could not determine. The conjunctival ecchymosis termi-
nated abruptly at the limbus conjunctivae, from whence, in the direction of the
wound, there was only a non-vascular infiltration. It is also possible, he ob-
serves, that no blood escaped by the wound, but that the strong suction alone
used the intra-ocular and extra-ocular hemorrhagy .-^ 6rZas^ott/ Medical Journal,
April, 1862.

62. Piece of Stone Imhedded for Seven Months in the Cornea. — Dr. Wm.
HuTCHiNsox records [Dublin Medical Press, March 26, 1862) the following
example of this : —

On the 26th of July, 1861, a man, set. 56, presented himself " suffering under
intense pain, and covering his left eye with his hand, on removing which I at
first sight thought I saw the iris protruding through the cornea, but changed
my opinion at once seeing it was exactly in the centre of the cornea. I asked
him his history of his case, and he told me he had been breaking stones for the
road in the week before Christmas, 1860, just seven months, and he thought a
piece of the stone (which I inclose herewith) struck him in the eye, and he had
intense pain, &c. Strange to say he was treated for the seven months as a case
of procidentia iridis, and was suffering the same pain all that time. I got a
cataract forceps, and brought out the little piece of stone without using any
force-. The aqueous humour followed in a jet. The poor man was greatly
delighted at the cessation of the pain. The cornea in this case had wonderful
endurance, for it remained in a perfectly sound state, notwithstanding the long
continuance of the hard body imbedded in its substance exactly opposite the
pupil for seven months. He was discharged on the 5th of September, seeing
nearly as well as ever.

63. Rectification of Divergent Strabismus by the Methodical Use of Pris-
matic Glasses. — An eye affected with squinting, as our readers are aware, sel-
dom takes any share in binocular vision ; when it contributes to the function, it
is but in a very limited degree, and only provided the divergency is moderate.
In general the deviating eye has separate sensations, and the healthy eye alone
is used by the patient.

If, under these circumstances, the image of objects seen by the healthy eye
be placed before the inert organ with the assistance of a prismatic glass of an

260

Progress of the Medical Sciences,

[July

angle proportionate to the degree of the squint, both eyes will be in possession
of two similar images, at the intersection of the ocular axes, and coalescence of
the two figures, and subsequent visual perception of a single object will be the
result.

Both eyes are thus artificially brought into simultaneous action; but for
restoration of the regularity of the ocular axis nothing yet has been done. Now,
if instead of the prism above described, the angle of which (at the summit) would
be about double the angle of deviation of the eye, a prism is used of a slightly
smaller angle, inferior, for instance, by two or three degrees to that of the devia-
tion, each organ still receives the impression of the object, but not precisely at
the same focus. The images are seen double, but in close approximation, crossed
if the strabismus is divergent, superposed if internal.

In accordance with Wheatstone's law on binocular perspective, the tendency
of the patient is to exert himself continually to neutralize the diplopia, and as,
on account of the angle of the prism, the images are very close to each other,
the instinctive effort overcomes their separation ; they soon blend, and as this
result is due to the agency of the muscles of the divergent eye, a part, however
small, of the deviation is thus corrected.

When the diseased eye has, by uninterrupted exercise of a certain duration,
say about a week, gained a little in the right direction, another prism of a smaller
angle is used, and the eye is for another week compelled to fresh exertion, and
after a short time binocular association is gradually restored.

On these principles. Dr. Giraud-Teulon, formerly a pupil of the Polytechnic
School, and the author of a recent treatise on the physiology and functional
pathology of binocular vision, rests his treatment of squinting in a case recorded
in the Gazette Aledicale.

On the 24th of April of the present year, a young lady, aged 17, was presented
by Mr. Demarquay to M. Giraud-Teulon, as an instance of strabismus resulting
more probably from functional than from anatominal disease. The right eye, in
which existed some slight corneal opacity, was considerably divergent ; the outer
edge of the cornea being in contact with the external canthus in more than 20
degrees' deviation. No muscular retraction was present, but some slight spas-
modic movements were observed, and the eyeball moved freely from one side of
the orbit to the other. In the healthy eye the visual function was perfect, but
the other was decidedly myopic. Thus, in order to read with this eye alone, the
patient was obliged to use a biconcave glass. No. 14;' and to read without effort,
with both eyes together, the divergent eye required the assistance of a prism
(with its summit turned outwards) of 18 or 20 degrees.

From these data, M. Giraud-Teulon concluded that the great disparity in
vision between the two organs was the cause of squinting, and ordered the pa-
tient to wear glasses constructed as follows : Before the left eye a plane glass,
No. 0, and before the right a biconcave glass. No, 14, in contact by its external
surface with a prism measuring at its summit (turned outward) 14 degrees.

The treatment was instituted May 4th.

Every eight or ten days the angle of the prism was reduced by about two
degrees, and the axis of the eye restored in a corresponding amount to its natural
direction. A singular circumstance was then observed: in proportion as the
divergency decreased, and as binocular vision was accomplished with weaker
glasses, the patient complained that the sight of the sound eye was becoming
shorter. M, Giraud-Teulon then measured the range of vision in this eye, used
singly, and found it what it was at the beginning of the treatment ; he again
measured it, both eyes acting together, and to his surprise discovered that the
originally healthy eye had become myopic in binocular association.' He then
resumed the treatment, substituting for the plane glass of the left eye a bicon-
cave glass, No. 14, as on the other side, and after two months' perseverance
binocular vision was restored, natural as to direction, but myopic on both sides.
Towards the 15th of July the patient was even compelled to exchange her
glasses for biconcave spectacles. No. 12, and all further artificial rectification
by means of prisms was abandoned. All that could be expected in this case

French scale.

1862.]

Midwifery.

261

was thus attained, and the patient must persevere in the use of the common
lenses used by myopic persons, with the assistance of which she is enabled to
perform all the duties of life. — Glasgow Medical Journal, April, 1862, from
Journal of Practical Medicine.

64. Hemorrhage into the Anterior Chamber of the Eye, supplementary to the
Menstrual Flux. — M. Guepin relates the curious case of a young lady, aged 18,
of good constitution, with a delicate skin, and somewhat lax tissues who com-
menced menstruating three years since. The menses returned every thirty or
thirty-two days with tolerable regularity, lasting sometimes but one day, and at
others five or six, and generally three days, the quantity of fluid lost thus vary-
ing greatly. She has always found that on the cessation of the menstrual flux
there has been a supplemental epistaxis, this being more or less abundant in
inverse proportion to the quantity of menstrual fluid lost. On one occasion,
however, the epistaxis did not appear, and then a sudden effusion of blood into
the anterior chamber took place, which brought her under the author's notice,
the menstrual discharge on this occasion only having lasted two hours. The
lower part of the anterior chamber was filled with blood, which rode over the
free edge of the iris. The author believes the case to be unique, the one nearest
approaching to it being an example of hemorrhage into the vitreous humour in
a subject of amenorrhoea reported in the thirty-fifth volume of the Annales. —
Med. Times and Gaz., March 29, 1862, from Annales d' Oculistique, Yol.
XLYI.

MIDWIFEEY.

65. Mechanism of Labour. — Dr. Halahan read before the Dublin Obstet-
rical Society the following paper on this subject : —

" The position in which the head of the foetus enters and passes through the
pelvic cavity during labour, has long occupied the attention of many midwifery
practitioners, and given rise to a great deal of discussion. But I am convinced
every practical man must allow that the description given by Naegelfe, is the
accurate, and also the only correct one ; and that the practitioner cannot, with
any degree of truth, contradict the statement that the head, at the full term of
gestation, enters the pelvis in the four positions described by him. I shall here
briefly enumerate them, the first has the anterior fontanelle directed to the right
sacro-iliac synchondrosis, and the posterior one towards the left foramen ovale ;
the second, is where the anterior fontanelle is, to the left sacro-iliac synchon-
drosis, the posterior one to the right acetabulum; the third is the reverse of the
first, and the fourth of the second.

"I am equally certain that those who pursue the study further, will agree with
me in saying, that although the head enters the brim in the before-named four
positions, yet, at the commencement of labour, when the os uteri is barely be-
ginning its dilatation, the anterior fontanalle is always directed towards either
acetabulum or presenting in the third or fourth positions of Naegel^. That the
fourth changes, at the beginning of labour, into the first ; and the third does
not change into the second until the head is distending the perineum ; that this
is the general course, any other being an exception.

"That to diagnose the position in the first stage of labour, is one of the diffi-
culties that the accoucheur has to overcome, I am fully aware of. Nothing but
constant attention, very extensive practice, together with a delicate touch, will,
with any degree of certainty, conquer the obstacles, and make him master of this
part of his profession ; for, although in theory it seems very easy indeed to be
able to diagnose positions, or to say which fontanelle presents at either aceta-
bulum, we find, in practice, it is one of the most difficult points to be perfectly
satisfied about, particularly when the head is high up, the membranes entire, and
the OS uteri not more dilated than to the circumference of a shilling.

"If, then, it is a fact that at the commencement of labour the face is always

262

Progress of the Medical Sciences.

[July

directed towards the pubes (and I have taken the greatest care and trouble to
be perfectly certain, and have fully satisfied myself that it is so, not by the mere
examination of a few ordinary cases, but by the most careful and constant inves-
tigation of some thousands of patients which I had the opportunity of watching
from the commencement of labour until the completion of the second stage),
there arises the question, how is it we so seldom find the head in the fourth
position when entering the brim, or even in that position when the os uteri is
half dilated, but on the contrary, generally discover it in the first? Whereas, in
the third, it is the exception for the change to the second to take place until at
the termination of the second stage. The simple answer is, that when the pos-
terior fontanelle is on a lower level than the anterior, the change takes place
immediately after the accession of labour, or, in other words, when the chin be-
comes depressed on the chest, or flexion of the head occurs early, which is the
case in the presentation of the head in the fourth position. But in the third, we
generally find the anterior one a little lower, or on a level with the posterior, the
head being neither flexed nor extended, which prevents the change taking place
until the posterior one becomes the low^er. This seemingly slight difference in
the two makes a very great one in the effect of the uterine action in its effbrts
to expel the head, and make the change which I shall now try briefly to explain.

" I presume all will allow that the pain or force pf the uterus takes its course
in the axis of the pelvis, and that the entire power may be directed effectually,
and with as little loss as possible, it is necessary that the occiput should move
in the same axis. This is the case in the first and second positions of Naegele ;
consequently, if the head enters the brim in either of these positions, we should
expect that labour will proceed favourably. If we examirre a patient at the
commencement of labour and find the head presenting in the fourth position, the
posterior fontanelle will generally be the lower or most easily reached by the
finger, the anterior one being very high up, and felt with difficulty. This admits
of the uterine force having full power on the head, and the change taking place
at once. But when the anterior fontanelle is on a level with, or a little lower
than the posterior one, the greater part of the uterine force is lost, being divided
between the occiput and sinciput. This can only be understood by remembering
the direction the uterine force takes, as well as the part of the head it has most
power on, as we will there see that when the forehead is the lower part, the pain
has not its full effect on the head, but that there is a loss of power. This is the
case in the third position, which I think clearly shows the reason that the head
enters the pelvis in the second position so rarely. Again, if we find the anterior
fontanelle presenting, in fact, midway between the sacrum and pubes, in the
third or fourth position, we may naturally expect that the labour will be rather
protracted, and the second stage very much prolonged, for the head will, with
very few exceptions, be expelled, face to pubes.

"It may very reasonably be asked, is there any practical use in being able to
diagnose in what position the child's head is presenting? Certainly there is, the
greatest. I shall merely mention two instances. In applying the forceps, we
always intend and wish to place the pubic blade over the ear, which will be felt
a little to the right or left of the pubes. Supposing, then, you have the instru-
ment correctly placed, is it not of very great importance to know which ear is
towards the pubes, as in the first and third positions, we have the ear in the
right half of the pelvis ; but if, not knowing the head is in the third, we try to
rotate as if it were in the first, we bring it out, face to pubes, which is not so
favourable as if we had changed it into the second position, the occiput not
adapting itself to the hollow of the sacrum in the same manner in which the face
does ? Again, if version is to be performed in a head presentation, is it not of
the utmost importance to ascertain whether the feet are lying towards the abdo-
men or back of the mother, whereby we may know which hand to use in perform-
ing the operation, and this fact can only be ascertained by an accurate knowledge
of the position?

"I have put in a tabular form five hundred cases, in which the head has en-
tered the pelvis, showing the relative frequency of the four positions of Naegele,
taken indiscriminately from the beginning of this year. It will be seen that the
first position is the most frequent of all, being 61 per cent. ; the third next, being

1862.]

Midwifery,

263

31.60 per cent.; the fourth next, being; 6.40 per cent., and the second least of
all, being 1 per cent. That the third changed to the second in every four cases
out of five, or nearly so, the proportion being 79.75 that changed, and 20.25
expelled face to pubes. The fourth changed into the first in 84.37 per cent.,
and continued as it entered the pelvis in 15.62 per cent.

The Ascertained Positions in 500 Cases, 1861.

POSITIONS OF NAEGELE.

1st

.3d

Primary

3d
changed
to 2d.

Total,
3d
Position

4th

Primary

4th
changed
to 1st

Total,
4th
Position

Total in 500 cases .
Percentage . , .

305
61

5
1

32
6.40

126
25.20

158
31.60

5
1

27
5.40

32
6.40

" Of the 158 cases in the third position at the commencement of labour, 126,
or 79.75 per cent, changed to the second; and of the 32 cases in the fourth, 27,
or 84.37 per cent, changed to the first in the progress of the labour." — Dublin
Quarterly Journ. Med. Sc., May, 1862.

66. Induction of Premature Labour in Cases of Constitutional Affections. —
Dr. Keiller, at the meeting of the Edinburgh Obstetrical Society (February
21, 1861), remarked that cases occasionally occurred where pregnancy was asso-
ciated with various constitutional diseases in such a way as to render it incum-
bent on the practitioner to induce premature labour, with the view either of
saving the patient's life or of mitigating her sufiferings. He wished to bring
before the society the history of some cases of this kind, which had recently
come under his own observation, and in which he had had some difficulty in
deciding as to the propriety of the operation.

1. Double Bronchitis. — He had lately had a case of acute double bronchitis
under his care in the hospital, where the difficulty of breathing was so great that
the patient sometimes appeared in danger of death from suffocation ; so that, on
more than one occasion, the officers had been summoned from the surgical de-
partment under the idea that it might be necessary to have recourse to trache-
otomy. As the dyspnoea was greatly increased in consequence of the tumid
condition of the abdomen, premature labour was induced, greatly to the advan-
tage of the patient, who felt speedy relief, and who soon afterwards recovered
completely. The child, however, had not been quite viable.

2. Phthisis. — The history of the next patient, whom he had had under his
care in the Infirmary, he would give as it had been drawn up by his clinical
assistant : —

"-M. D., set. 36, was admitted into Ward XIII, on the 24th September, 1860.
She was married, and had had eight children. On admission, she was suffering
from phthisis ; and on examination the left lung was found to be very much dis-
eased. At this time she said she had not menstruated for four months. The
uterine bruit could be detected, but not the foetal heart — a few weeks after ad-
mission, however, it could be distinctly heard. During the next three months
the disease of lungs advanced rapidly ; the enlarging uterus, gradually encroach-
ing on the chest, caused severe attacks of dyspnoea, and she often started from
her sleep with a sensation of sufi'ocation, which was generally relieved when she
assumed the sitting posture.

" Qth January. — She says she is now at the eighth month of utero-gestation.
Dr. Keiller thought there was a chance of saving the life of the child by inducing
premature labour, and thereby at the same time freeing her from the frequent
attacks of dyspnoea.

"Labour in this case was very easily induced. At 9 P. M. an examination

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Progress of the Medical Sciences.

[July

was made, and as the os and cervix uteri were soft and dilatable, one finger was
passed through the os with comparative ease, and the membranes separated to
a small extent around it. At 11.30 P.M. she had had a few pains. Examined
again and found the os dilated so much that two fingers could now be passed
into it, and the membranes separated still further.

" At 6 o'clock next morning the os was fully dilated, and a large bag of
membranes protruding. As the right shoulder was the presenting part, turning
was practised and the child brought away alive. The placenta was expelled
soon after the child, and the uterus contracted pretty well. Little hemorrhage
occurred after the expulsion of the placenta. The child was born alive, but was
small and weakly.

"The patient's breathing was very much relieved during the next fortnight;
but, about three and a half weeks after delivery, she died completely exhausted
by the disease of the lung."

3. Cardiac Disease. — He had at present under his care another patient, who
was pregnant for the first time, and was of a very delicate constitution. She
suffered from enlargement of the heart ; and although there was no distinct
physical signs of any affection of the lungs, yet her case was a very anxious
one, as was a member of a very phthisical family, and had herself had some
haemoptysis a short time before. He (Dr. Keiller) did not think it would be
necessary in this case to induce premature labour, but thought it extremely
probable that it might be found necessary to apply instruments early to hasten
labour when it supervened.

4. Cerebral Disease. — Another patient, about seven months pregnant, whose
case he thought worthy of mention, had been for some time in the Infirmary
under the care of his colleague. Dr. W. T. Gairdner, who regarded the case as
one of general paralysis. She had become very much reduced in strength, and
had been sent into his (Dr. Keiller's) ward with the view of having premature
labour induced. She is the mother of seven children ; suffered during her last
two confinements from puerperal mania of short duration, and about six months
ago was observed to suffer from loss of memory and general debility. The
patient was unable to give much account of herself; and the facts just stated
had been obtained from her husband, who had reminded Dr. Keiller that he had
seen the patient, about eight years ago, on the occasion of one of her confine-
ments, when she was greatly exhausted by a flooding, from which, however, she
had slowly recovered. He (Dr. Keiller) believed the patient to be the subject
of chronic cerebral disease, and although she had been several weeks under his
care, he had not deemed it necessary to have recourse to the induction of pre-
mature labour, because there seemed every probability that she would be able
to carry the child to the full time, and because, as yet, the child was hardly
viable. There was this peculiarity in connection with the case, that the abdo-
minal and uterine walls were so thin and lax that the foetus could easily be moved
about in the interior of the uterus by external palpation. The following were
the notes of the case as recorded by his assistant : —

" S. C, set. 38, married. Admitted into Dr. Gairdner's ward, December
13, 1860, suffering from amentia and debility. She is the mother of seven
children. During her last two confinements she suffered from symptoms of
puerperal mania, but in a few weeks after each confinement she recovered
completely. About six months ago she was observed to suffer from loss of
memory and debility, and she gradually fell into the state she was in on admis-
sion to Ward XV.

"After a residence in Ward XY. of two months, she was rapidly losing
strength, and she was sent to Ward XIII., under Dr. Keiller's charge, in order
that premature labour should be induced to save the child.

" As Dr. Keiller, however, did not think the time of utero-gestation far enough
advanced, and as she improved in general health, the induction of premature
labour was deferred."

5. Fatal Vomiting. — Finally, he wished to mention, in connection with these
cases, the case of a woman who had had several children previously, and had
never suffered from any abnormal sickness or other morbid symptoms during
her pregnancies, but who had died, about the third or fourth month of her next

1862.]

Midwifery.

265

pregnancy, of excessive vomiting. In this case he (Dr. Keiller) regretted that
abortion had not been induced, as, on post-mortem examination, there was no
evidence of any other cause for the vomiting except the pregnancy ; and if the
uterus had been made to discharge its contents, the secondary and fatal symp-
tom might probably have been relieved. — Edinh. Med. Journ., March, 1862.

67. Internal Surface of the Uterus after Delivery, — Dr. J. Matthews Duncan
read a paper on this subject before the Obstetrical Society of London (May 7,
1862), in which he proposed to show that as the modern ascertainment of the
true condition of the decidua or mucous membrane of the uterus in early preg-
nancy was a great acquisition for physiological science and for practical medi-
cine, the completion of our knowledge of the condition of the same part in the
end of pregnancy and after delivery would be equally if not more valuable. Our
understanding it thoroughly would contribute greatly to our comprehension of
various post-partum diseases, and especially of the heterogeneous aggregation
included under the name of puerperal fever. In regard to both of these sub-
jects, the writings of William Hunter had been grossly misinterpreted. Errors
which his brother John had introduced had been attributed to him, while a
careful scrutiny of his writings showed that he held and taught, though in an
imperfect manner, the modern and undoubtedly correct views regarding the
decidua of early pregnancy, and the state of the mucous membrane after deli-
very. Cruveilhier was the anatomist on whose authority most modern authors
rested, asserting that after delivery the whole internal surface of the body of
the uterus was left, like an amputation-stump, a bare muscular surface, and that
healing was effected after a process of suppuration and granulation. This
theory was quite inconsistent with physiological and pathological laws, and with
the known facts regarding the uterus and the lochia. Heschl accepted the
statement of Cruveilhier regarding the denudation of the muscular fibres of the
uterus, and only suggested a new theory explanatory of the mode of healing of
the surface. Dr. Matthews Duncan maintained that at no time was the mus-
cular tissue laid bare ; that a layer of mucous tissue was left everywhere cover-
ing the proper muscular structure ; that, as the uterus diminished in size, this
mucous tissue increased in thickness ; and that healing took place by a process
analogous to that followed by the skin or any mucous membrane denuded of its
superficial portions. He had particularly to point out that this was true of the
placental site, in which the persistently open uterine sinuses, after a rich mucous
membrane was evident, showed that no new membrane was formed over the old
placental surface, as Cruveilhier and Heschl imagined, but that the remains of
the decidua serotina reconstructed a new mucous membrane. The author
alluded to the valuable contributions to our knowledge of this subject from
Priestley and Robin, and commented on the ignorance or neglect by the latter
of all but French observations on this subject. He did not agree with the
opinion of Robin, adopted by Priestley ; that the old uterine mucous membrane
is detached about the middle of pregnancy, and a new one then begins to be
formed. This notion was quite inapplicable to the placental site ; it was quite
in opposition to the fact that at no time was the internal surface of the uterus
found denuded of mucous structures ; and no sufficient observations were ad-
duced on which it could be founded. The new views regarding the internal
surface of the uterus after delivery were in accordance with all the other known
facts on this subject, especially the absence of inflammation and the nature of
the discharges after healthy delivery. — Med. Times and Gazette, May 17, 1862.

68. Unsuspected Pregnancy and Labour. — Dr. H. Tanner related to the
Obstetrical Society of London (May 7, 1862) the following case of this. He
was sent for April 17, at nine o'clock in the morning, to see Mrs. J., aged forty-
two years, who had been suffering pain in the abdomen since eleven o'clock on
the preceding night. The patient stated that she had been married rather more
than three years, and that she had never been pregnant. The catamenia were
last on some time in June, 1861, but as they had been very scanty for five or
six months before, their cessation was attributed to the " change of life." The
abdominal pain came on in paroxysms ; it had been unrelieved by medicine and

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a mustard poultice ; and the assistant of a surgeon in the neighbourhood had
pronounced the suffering to be due to flatulence and inflammation. This
opinion coincided with that entertained by the patient, as well as with the views
of the husband, mother-in-law, and a married sister, who had been sitting up
with her. On examination it was found that the lady was in labour, the mem-
branes being ruptured, the os uteri dilated to the size of a crown-piece, and the
head of the foetus entering the brim of the pelvis, with the vertex presenting.
In a few hours Dr. Tanner effected delivery with the forceps, the child (a female,
arrived at maturity) being born with animation suspended ; it was, however,
restored by the persevering use of artificial respiration, to the gratification of
the astonished parents. This case serves to establish as a fact — that a woman
may conceive, may go to the full term of gestation, and may be in labour for ten
hours, without having any suspicion that she is pregnant. — Ihid.

69. Twins; One Dead at Six Months; Both Retained until full Term. —
Dr. Flecken relates a case in which a powerful woman was delivered of a strong,
living, and full-timed child. After the expulsion of a very large placenta, another
compact, fleshy placenta, in partial connection with the former, followed; the
accompanying membranes contained a sixth-month foetus, the body of which had
been compressed so flat that the broadest part of the cranial and thoracic regions
did not exceed five lines. The bones of the cranium lay separated from each
other, the nasal bones projected as sharp points, and the broken malar bone
penetrated the skin. While in the sixth month of her pregnancy the woman
had fallen down stairs. — Med. Times and Gaz., March 29, 1862, from Berlin
Med. Zeit., No. 2.

70. Diagnosis of the Sex of the Foetus. By Dr. Stetnbach, of Jena. — The
question I am about to consider is comparatively so new, the observations re-
garding it are so isolated, and are so much in opposition to the statements of
Dr. Frankenhauser, that it cannot by any means be regarded as settled. Only
a long series of observations, carefully instituted and free from prejudice, can
determine whether or not there is any truth in Dr. Frankenhauser's discovery
that a low average of the cardiac pulsations in a foetus indicates a boy, while a
high mean is symptomatic of a girl. In the following pages I off'er a small con-
tribution to this inquiry. It is evident that observations of this kind can only
be undertaken where material is abundant, and where there is plenty of time at
the disposal of the observer ; while acting as assistant physician to the Lying-in
Hospital of Jena I had the favourable opportunity in question. It was not with-
out some misgivings that I begun and carried on my observations upon 56 preg-
nant women, in the course of the summer of 1859, but at the end of that series
I was able to discontinue my observations, as they almost exactly confirmed the
doctrines of Dr. Frankenhauser, for out of the 56 cases in question I was wrong
in predicting the sex only 13 times, and my errors were in cases into which, on
account of their peculiarity, it will be necessary to inquire further on, in order
to estimate their value in determining the sex of the child. (Here follows a
table which contains the results of the examination of the foetal heart with regard
to frequency, made morning and afternoon, from the time of the woman's enter-
ing the hospital until the commencement of labour.)

I must now premise a few observations, partly with regard to the examination
in general, partly regarding the precautions to be observed, and which ought to
be attended to if any result of value is to be obtained.

I did not content myself with examining the pregnant woman two or three
times. It is soon found where cases are for some time under observation, that
considerable variations in the frequency of the foetal heart occur, and hence a
somewhat extended series of examinations is necessary to determine the mean
number of its beats. Accordingly I auscultated each pregnant woman every
day, morning and afternoon, commencing on the day after her admission into
the institution, and continuing my observations until labour set in. It often
happens that the observations only commenced in the last days of pregnancy ;
but, on the other hand, there are a good many cases which were observed during
a month and even more before labour occurred, and these confirm the observa-

1862.]

Midwifery.

26t

tions of others that with the advance of pregnancy a diminution in the frequency
of the pulse of the foetus, corresponding with its increasing development, does
not take place. I would willingly have instituted observations on the foetal pulse
at a much earlier period of pregnancy ; but this, by the rules of the institution,
was impossible, as with few exceptions no patients are admitted gratuitously
before the last month of pregnancy.

I counted the beats of the heart during a quarter of a minute, and if I found
considerable variations from the number I had formerly noted, I counted again
several times, and finally took the mean of the observations with regard to varia-
tions of the pulse, which, according to some observers, often show considerable
differences; it is not to be denied that they do occasionally occur, yet in con-
tinuous observations they either equalize themselves, or they are entirely lost in
the general sum of the observations. I may mention the two cases in which the
differences were the greatest, but in which the exceptional numbers were quite
isolated. In the first (a boy), where the variations of the frequency of the heart
were on the whole inconsiderable, I found the foetal pulse one morning fallen so
low as 108 without any assignable cause ; in the second (a girl), it maintained
for some time a frequency of 192.

In reference to the two extreme numbers fixed on by Dr. Frankenhauser, by
means of the variations below or above which we are to determine the sex of
the child, I am not entirely at one with him. Though from my observations I
have found 131 to be the mean number for boys, and 144 for girls, my extreme
number oscillated between 133 and 143, certainly not an unimportant interval
in opposition to the assumption of Frankenhauser, according to whom 136 is
the extreme number. I do not, however, consider it necessary to rely on a
particular number, because, as I have already stated, slight variations which
may range from 1 to 10 may be present, and because slight errors in counting
during a quarter of a minute cannot be entirely avoided. But is it not enough
if it is only proved that the higher numbers correspond to girls, the lower to
boys? In reply to this I must state that mean numbers under 136, which
belong to the male sex, are far from not showing such variations as up to 140,
and even higher, and I confess that I should have much more confidence in
diagnosing a boy if I repeatedly found the frequency of the pulse between 124
and 132.

On account of the diflficulty of observations of this kind, I think it not unad-
visable to recur to the mode in which the examination is to be performed, and
to mention the sources of disturbance and the precautions to be avoided, in order
that the foetal heart may be accurately counted.

The reason of incorrect or not altogether exact observations depends some-
times on the observer, sometimes on the person under examination, sometimes
on the foetus, and not unfrequently upon all three.

An inconvenient position on the part of the observer, which may lead to sleep-
ing of the foot and consequent shaking, or to congestion of the head with accom-
panying hallucinations of hearing, is always a source of disturbance. The most
suitable position is that in which the observer is not at all in his own way ; there-
fore the woman should lie on her back with the head moderately raised, in as
comfortable a position as possible, towards the edge of the bed on which the
observer is half seated, and from which he bends forward.

Of still greater importance are the sources of disturbance on the part of the
pregnant woman ; among these I might reckon — 1st. Her uneasy position, on
account either of her nervous dread of the unusual examination, or of dyspnoea,
aggravated by the recumbent posture, or the susceptibility of the parts about
the uterus, in consequence of which, on the application of the ear or the stetho-
scope, the walls of the abdomen are put in motion by the contraction of the
muscles by which a disturbing noise is produced. 2d. Sounds generated in the
intestinal canal ; the communicated breathing of the mother ; the sound of the
beating of her abdominal aorta. 3d. The contemporaneous occurrence of ute-
rine bruit, which may drown all other sounds.

Still more complicated are the difficulties which may be occasioned on the
part of the foetus. The principal of these are — 1st. Its reflex movements, which
very often, if not always, are called forth by the straight position of the mother,

268 Progress op the Medical Sciences. [Jnly

as also by the application of the stethoscope or the ear to her belly, and we must
often wait for a ininute (during which time I remove neither the stethoscope nor
the ear from the belly) until the violent movements of the foetus, and with them
the accelerated and unrhythmical action of the heart have subsided. 2d. The
occurrence of considerable differences in the frequency of the pulse, which may
occur without any assignable external cause, and which may depend upon some
unknown conditions of the foetus, or perhaps upon some peculiar state of the
maternal organism. 3d. The sudden occurrence of a murmur in the umbilical cord,
which not only may make it difficult to count the pulsations of the foetal heart,
but what is of more consequence, may produce a difference in the frequency of
the pulse, a circumstance which was also noticed by Frankenhauser. It is best
to wait until the murmur has disappeared, for where it remains audible and un-
interrupted from day to day, it becomes necessary to abandon the observation
of the case. 4th. The difference or rather the change of the double beat, con-
sisting in this, that at one time the first sound of the heart, at another the second
becomes more marked, which resembles unrhythmical action of the heart, and
often makes it necessary to begin to count afresh.

I shall now return to the 13 cases, an analysis of which I promised at the
beginning of these remarks.

The first case should be excluded from this series of observations. From
the mean frequency of the pulse (141), 1 inferred the presence of a girl; but
these turned out to be twins, which, on account of the great distension of the
uterus, it would have been impossible to diagnose. It is right to add that the
twins were both boys.

The 2d and 3d cases should likewise be excluded, as, indeed, not the mean
number, but the series of single numbers would perfectly have corresponded to
a child of either sex. But in these, especially in the 3d case, the mean number
cannot be employed, because variations occurred which could not in any way
be accounted for.

Cases 4 and 5, and 6, 7, 8, 9, constitute two groups of much interest. I must
here remark, that in the course of my inquiries I made simultaneous observa-
tions upon the pulse of the mother. I thereby endeavoured to answer the ques-
tion, whether and how far the frequency and quality of the maternal pulse as an
index to the healthy or unhealthy condition of the mother, can have an influence
on the life of the foetus, and in what way it would manifest itself upon the latter.
The two first-mentioned cases (4 and 5) appear to answer this question. In case
4 the mean frequency of the foetal heart was 145 ; the mother was pregnant for
the fourth time, and was suffering from tabes dorsalis ; her pulse was on an
average 92. In case 5, the mean frequency of the foetal heart was also 145 ;
the mother, a primipara, was suffering from chronic metritis, which was subject
to occasional exacerbations ; the average of her pulse was 97. In each of these
cases the constant high number of the foetal pulsations justified me in assuming
the presence of a girl ; it turned out, however, that both were healthy boys.
Whereas, on the one hand, it would be premature to draw from these two cases
the general conclusion, that disease of the mother, with quickened circulation,
increases the rapidity of the foetal pulse; yet, on the other, it would be worth
the trouble, and it is strongly to be recommended, that other observations
should be instituted upon this point, particularly as Hohl relates that, in the
case of a pregnant woman suffering from smallpox, the frequency of the foetal
heart was 260, and six hours after its birth the infant was covered with a vario-
lous eruption.

The group 6, 7, 8, 9, is perhaps still more interesting. The mean frequency
of the heart's beats in these cases was 131, 147, 135, 136. In the two first
cases a murmur in the umbilical cord was constantly present; in case 6 the
child was born with the cord twisted twice, and in case 7 with it twisted once
round its neck. In cases 8 and 9 an umbilical murmur was almost constantly
present; at birth there was no twisting of the umbilical cord, but in both cases
it was very thin. However, in all four cases, pressure upon the cord was the
cause of the murmur. But that an umbilical murmur, depending upon pressure
of the cord, goes along in all cases with a diminution in the frequency of the
foetal heart, as seems to be borne out by cases 6, 8, 9 (where boys were expected,

1862.]

Midwifery.

269

but where g-irls were born), is contradicted by case 7, where the conditions
were reversed, I having been led from the frequency of the foetal heart to expect
a girl, but where a boy appeared. But still less should it be denied that
pressure on this cord (as indeed I have had other opportunities of observing,
especially during the course of labour) may exert an influence on the fcetal heart,
and may be an obstacle to determining the sex of the child by the way we are
now considering.

There remain now only cases 10, 11, 12, 13 ; cases certainly in which there
appears to be no explanation of the erroneous diagnosis arrived at, except that
the observations extended over comparatively too short a time.

Accordingly, the thirteen cases which I have now described may with pro-
priety be looked upon as exceptions to the rule, and accordingly the errors in
the determination of the sex of the foetus are reduced to the last four cases,
and the results of my observations speak even more strongly in favour of the
law 1 have endeavoured to illustrate than the language I have employed at the
commencement of this paper.

Finally, I may mention two cases, which have indeed nothing to do with the
diagnosis of the sex of the foetus, but which, in another point of view, are of
considerable interest.

In the first, during the last nine days of pregnancy, in spite of all the pains
which were taken, the sounds of the foetal heart could not be heard, although
during the previous three weeks they had always, with the exception of a single
afternoon, been clearly recognized ; accordingly, though all other signs were
wanting, I diagnosed the death of the foetus. At birth the epidermis of the
foetus was already separating, and was hanging in loose shreds from many parts
of the body. I mention this case as noteworthy, because it shows, that if the
sounds of the heart, which had previously been heard without interruption,
cease to be audible, we have a right to consider that the foetus has died. It is
no doubt true that the sounds of the heart may disappear from time to time,
though not nearly so often as is generally believed ; this only happened 9 times
out of my 56 cases.

The second is the only case in which I had an opportunity of noting the sounds
of the foetal heart at an earlier period of pregnancy than in the others, the woman
having been delivered during the 34th week. Here I predicted from the mean
frequency of the pulse (141) that the foetus was a girl, and the result corresponded
to my expectation ; in other words, the state of the foetal pulse even some time
before its birth affords us a means of determining its sex.

I may briefly recapitulate the various circumstances which, according to my
observations, may interfere with the certainty with which the sex of the foetus
may be inferred. 1. Too short a period of observation, which does not give an
opportunity for detecting variations which may be considerable. 2. The last
days of pregnancy. 3. Insufficient care on the part of the observer. 4. Several
pregnancies. 5. Those cases where the frequency of the pulse might corres-
pond to either sex. 6. Diseases of the mother. 7. Pressure on the umbilical
cord. 8. Cases in which the differences of the pulse do not as yet admit of any
explanation. It thus appears that there is still a wide field for the existence of
errors in diagnosing the sex of the child. — Edinh. Med. Journ., March, 1862,
from Monatsscliriftfur Geburtskunde und Frauenkrankheiten, December, 1861.

71. Epidemic of Puerperal Phlegmonous Erysipelas at Stockholm. By Prof
Retzius. — The new Lying-in Hospital of Stockholm was opened in May, 1858.
and six months had scarcely elapsed when some cases of puerperal fever occurred,
although not in rapid succession. . At the commencement of 1859, the cases
became more and more frequent, until they constituted 40 per cent, of the ad-
missions, and furnished a mortality of 16 per cent. The health of the hospital
improved during the summer, so that the puerperal cases only constituted 3 per
cent., and the mortality was reduced to 6.62 per cent. During the months of
November and December the cases rose again to 37 per cent., but the mortality
kept as low as 6.9 per cent. At the commencement of 1860, the weather was
very mild, and the number of admissions to the hospital were far beyond its
means of accommodating. As a consequence, erysipelatous inflammations soon

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manifested themselves, although no analogous form of disease prevailed in the
town. At the end of February and beginning of March, phlegmonous erysipelas
attacked the upper or lower extremities of several of the patients, little or no
pain of the abdomen existing, although the whole surface of the body was ex-
ceedingly sensitive to the slightest pressure. The patient's powers became
more and more depressed from the commencement to the fatal termination of
the affection. The lochial secretion was very fetid and excoriative. Neither
constitutional condition, prior disease, present debility, or the prolonged dura-
tion of labour, seemed to exert the slightest influence on the disposition to
become affected by this disease. Until the end of March, only the under floor
of the establishment furnished the cases, this being the part where the midwives
are instructed. No woman who occupied a room alone, having a space of 2.000
cubic feet, became the subject of the disease. In a room intended for three
women, with 1,500 cubic feet for each, there were placed, on account of the
influx, four women, and therefore with not more than 866 feet. Seeing the im-
propriety of keeping women long in such a room, with insufficient means for
keeping it cleaned and ventilated, it was closed against these cases. Still there
were sometimes placed in it cases of the ordinary peritoneal forms of disease,
which all terminated favourably. It was hoped by this closure the further spread
of the erysipelas would be prevented, but towards the end of April it broke out
again in quite another part of the establishment. Fortunately, the pressure of
admissions became slighter, and an effectual cleansing of the rooms and material
arrested its further progress. It is a curious fact, that during the residence of
the infants in the establishment, not one of them suffered from erysipelas, al-
though this is of so common an occurrence when the mother is the subject of
puerperal fever. The author was, however, informed that bad erysipelas did
attack several children who had been removed to the Foundling Hospital in
consequence of the deaths of their mothers from this disease.

At the autopsies, nothing very remarkable was observed with respect to the
abdominal viscera, or their peritoneal covering. The uterus was found in a
relaxed condition, its inner surface being lined with a fetid, purulent fluid, mixed
with coagula, the walls of the organ, on removal of this, being of an ash-gray
colour. The substance of the organ was, to two lines depth, loose and pulpous,
with the mouths of the vessels gaping. The heart was pale and flabby, coagula
being contained in its cavities. There was much stasis of blood, with oedema
of the lungs. On making incisions into the diseased extremities, much red serum
was discharged from the infiltrated cellular tissue, to which, however, the mor-
tification which had aff"ected the skin had spread only in a slight extent. The
muscles were of a pappy softness. The bloodvessels contained no coagula, nor
did the walls of the veins exhibit any signs of inflammation, and pus was found
only in the spermatic veins. The microscope showed that the colourless cor-
puscles of the blood existed in an unusually large quantity. — Med. Times and
Gaz., April 12, 1862, from Monatssclirift fur Gehurtskunde, vol. xvii. pp.
191—197.

72. Treatment of Peritonitis hy the Continued Application of Cold to the
Abdomen. — M. Behier, at the Session of the French Academy of Medicine,
April 1, 1862, reported the history of several cases of metro-peritonitis which
were rapidly cured by the exclusive application of continuous irrigations of cold
water upon the abdomen ; and then detailed the results that have been obtained
by him in the treatment of puerperal affections by the application of ice. M.
Behier applies the ice to the abdomen of the patient by means of gum caout-
chouc bags filled with fragments of ice, renewing them every two hours. M.
Behier stated that since October, 1858, 801 females were confined at the Hos-
pital Beaujon: to 355 of these females ice was applied; 244 of the patients
presented merely swelling of the annexes of the uterus, accompanied with slight
pain which speedily disappeared. In 68 the symptoms were of a more menacing
character, with a decided febrile reaction and a commencing alteration of the
patient's features. Thirty-nine of the 801 parturients died. But even in these
cases, the application of the ice postponed the fatal result beyond the customary
period at which it happens in cases where ice had not been applied. M. B6hier

1862.]

Midwifery.

271

hopes, therefore, that the employment of the ice will be a means well adapted
to counteract the affection of the peritoneum which is so common an element
in the diseases of the puerperal female. It seems to him to be especially ap-
plicable to cases unattended with any general affection. He remarks that, in
the numerous observations he has made, he has seen no injurious results occur
from the practice advocated by him — ^not the slightest disturbance of the lochia]
discharge, or of the secretion of milk. — Gazette Hebdomadazre for April, 1862.

73. Bronclio-Pneumonia of Lying-in Women. — Dr. Barnes communicated
to the Obstetrical Society of London (March 5) the following note. He stated
that observation had long made him familiar with the fact that lying-in women
were liable to a peculiar form of broncho-pneumonia. It had been generally
considered that the pulmonary symptoms which arise during childbed were the
consequence of the violent straining attending the expulsive stage of labour
and of " taking cold." To him this explanation was far from sufficient. As in
typhoid fever, so in puerperal fever, the lungs were apt to be involved. In either
case the cause was similar. It was observed that a marked characteristic of
typhoid fever was the extreme alkalinity of the blood. The urine he had fre-
quently found highly ammoniacal on voiding. A similar condition commonly
marked the blood in puerperal fever. On one occasion the author observed
that, the bladder being partially paralyzed, and the urine consequently retained
in the intervals of being drawn by the catheter three times a day, the urine de-
composed so rapidly in the bladder as to evolve large quantities of ammoniacal
gas, which escaped in a gurgling stream when the catheter was introduced.
These circumstances, with others which need not be enumerated, indicated a
dyscrasia of the blood which must produce certain irritating effects throughout
the body. The diarrhoea of puerperal fever, and the diarrhoea which frequently
happens in childbed apart from overt fever, were the simple effect of the irrita-
tion of the intestinal mucous membrane by the septic or other offending matter
circulating with the blood. Peritonitis arose in the same way. Accompanying
this diarrhoea, or apart from it, we might have broncho-pneumonia. This, in like
manner, was simply the effect of the irritation of the bronchial mucous mem-
brane or parenchyma of the lungs by the same offending matter. In some of
these cases the breath of the patient had possessed an odour distinctly resem-
bling that of the foul lochial discharges. It was by the complication of this
form of pneumonic irritation that the author accounted for the fatal accelera-
tion of phthisis after labour. This form of broncho-pneumonia was distinct
from that which immediately resulted from capillary embolia. — Med. Times and
Gaz., March 22, 1862.

74. Ovarian Tumour cured hy Tapping [?), and followed hy Two Preg-
nancies.— M. L. R. Cooke records [Med. Times and Gaz., April 5, 1862) the
following interesting case : —

" Mrs. D., aged 28, became a widow soon after the birth of her third child,
about the middle of the year 1858. Two months after the delivery she noticed
a new abdominal tumour, which gradually increased (meeting with various erro-
neous diagnoses) until June, 1860, when it had attained a size sufficient to em-
barrass her respiration, and to cause her much distress, more especially as she
was under an engagement to re-marry.

" Under these circumstances she applied to Mr, Spencer Wells, who diagnosed
a simple ovarian cyst, and tapped her, removing thirteen and a half pounds of
a viscid fluid.

" In July of the same year, finding no perceptible return of the disease, she
married; and, in May, 1861, I attended her during the delivery of a perfectly
healthy child. Her health has continued good up to the present time, and on
her lately announcing her expectation that her next delivery will take place in
the course of next month, I satisfied myself that her present condition is that
of advanced pregnancy, and is not due to a refilling of the old cyst.

" These facts appear to confirm the justice, either of the theory that in simple
ovarian cysts the mere operation of tapping is sometimes followed by adhesion
of the cyst walls and gradual degeneration of the cyst itself, as borne out by

212

Progress of the Medical Sciences.

[July

other published cases ; or, on the other hand (looking at the short time between
the operation and the subsequent pregnancy), the practice adopted by Mr.
Baker Brown of following the operation by pressure, with the view of obtaining
the same results.

" It appears quite possible that, on the one hand, the refilling of the cyst may
have been retarded by the new direction given to the activity of the generative
organs through the influence of the sound ovary ; and, on the other, that a slow
refilling may have been taking place, coincidently with pregnancy, until the
uterine tumour had acquired sufficient dimensions to exercise a pressure ade-
quate to promoting absorption.

Practically, the case teaches, at any rate, this much, that, given an ordinarily
favourable case for the use of the trocar — the additional facts of the patient
having exhibited a recent aptitude for conception, being married, and being
within the child-bearing period, may often constitute an inducement to us to
perform the operation with some hope of putting a period to the disease."

75. Intra- Uterine Convulsions. — Dr. James A. Sidey read to the Obstetrical
Society of Edinburgh (January 16, 1861) the following notes of a case of what
he might call " intra-uterine convulsions:" Mrs. T., aet. 40, a delicate, weakly
woman, sent for me about 11 A. M. on the 10th of April, 1860, to attend her in
her eleventh pregnancy. I found her in labour, with the os fully dilated and
the pains strong — the head presenting in the third position. A few pains brought
the head so low down that it pressed on the perineum ; but for two hours there
was no farther progress made, although the pains were strong and forcible. As
the four previous labours in which I had attended her had been very easy, I did
not understand why the head still remained about the same place, especially as
I could introduce my finger all round the pelvis ; but on inserting my hand I
discovered the hand of the foetus hitched on the pubis. This I relieved with
some difficulty, and a strong pain coming on, the child, a male, was born at 2
P. M. During labour the movements of the foetus were very violent, leading
me to suppose that it was convulsed. The patient did well. On examining the
child it presented the appearance of being well grown and at the full period, but
its arms were bent on its chest, with the elbows slightly extended from the sides,
and the fingers drawn together like a cone. I attempted to pull the arms down,
but could not with the amount of force I thought justifiable. The child cried
lustily, and got on very well for a short time, when twitchings of the muscles
generally came on, which soon ran into convulsions. In this state, ever twitched
or convulsed, the child lived for seven months, when it died much emaciated.
No treatment seemed to be of the slightest service except turpentine and can-
nabis indica, which had an evident efifect in preventing the convulsions — one
fluidrachm of sol. mur. morphia, given accidentally, only produced sleep for one
hour. The child died on '26th November, 1860.

Previous to her confinement, the mother told me that she was certain that the
child would be ill, as she had experienced the same sensations as she had felt in
her fifth and seventh pregnancies — these children, a boy and a girl, having been
born with the same disease (the one lived six, the other fourteen months). She
said that after the seventh month, on each of these occasions, she could not go
out in consequence (as she described it) of "shakings in her inside," which were
so severe as to make her " feel as if her inside would come out." Her third child
died of acute hydrocephalus at the age of six years.

Post-mortem examination was made by Dr. Sanders, who has kindly furnished
me with the following notes : The body was greatly emaciated. The arms were
in a peculiar position, being tightly drawn up ; the forearms rigidly flexed upon
the arms, so that they could not be straightened ; while the hands were clenched,
and the thumbs bent in towards the palms. The right leg was also contracted.
The leg was flexed upon the thigh till the heel touched the buttock. The head
was not larger than natural. On opening the cranium, a considerable amount
of serous effusion was observed under the arachnoid, filling up the sulci. On
section, the cerebral substance was of natural consistence, but the gray matter
was paler than usual and apparently infiltrated with serum. The lateral ventri-
cles were found much distended, and filled with serous fluid to the amount of

1862.]

Midwifery.

213

about ^iij in each ventricle. On examination the lining membrane of the ven-
tricles was found much thickened, especially in the posterior and descending
cornua. There was no tubercular deposit either in the ventricles or on the
surface of the brain. The other organs of the body were not examined. The
thickened lining membrane of the ventricles, viewed under the microscope,
showed a number of compound granular corpuscles. — Edinburgh Med, Journ.,
January, 1862.

76. Pathogen^/ of Retro-Uterine Hannatocele. — Prof. Braun has reported
ten cases of retro-uterine hsematocele, and the following are some of the con-
clusions at which he has arrived : 1. In the ten cases, the diagnosis was made
with certainty in eight, and with probability in two. Nine of the patients re-
covered perfectly ; in the fatal case there were extra-uterine pregnancy and
obsolete peritonitis. In seven cases, the indications afforded by exploratory
puncture were very encouraging. Puncture and entire evacuation of the
tumour were followed by cure in six cases ; in three, recovery took place under
passive treatment. In six cases, the haematocele was retro-uterine ; in four,
antero-uterine. In none of the cases did the extravasation surround the uterus ;
it was always confined to one-half of the pelvis. 2. Rapid cure may follow the
emptying of the haematocele by puncture ; the fertility of the patient is not de-
stroyed ; and a subsequent pregnancy and parturition may follow their normal
course. 3. Movable pelvic tumours, which careful palpation and examination
show to be probably hsematoceles, are recovered from under or after inunction
of iodine and glycerine. 4. The quantity of blood contained in a uterine hsema-
toceie may vary from a few drachms to several pounds. 5. The blood extrava-
sated in the neighbourhood of the uterus undergoes a metamorphosis ; the cor-
puscles become broken up, and their membranes appear flabby and eroded ; they
do not undergo putrefaction, and immediately after evacuation do not bruit a
putrid smell. When the hsematocele is of long standing, dark brown spots are
formed on its walls ; the blood-corpuscles are absorbed, and a greenish-yellow
fluid is left, having the specific gra^dty of the blood-serum, with an alkaline re-
action, and containing albumen, a very large amount of albuminate of soda, a
little biliverdin, no ammonia, very little sugar, but the salts of the blood-serum,
with a preponderance of the chlorides. The fluid removed by the trocar from
a hsematocele generally contains blood of a tarry, ropy consistence, not of bad
odour, with numerous patches of pigment, and with hsematin ; it also contains
crystals of ammonio-phosphate of magnesia, 6. During the existence of a
hsematocele, menstruation sometimes runs a normal course, without pain ; some-
times it is very profuse and painful, and is generally attended by enlargement of
the blood-cyst ; sometimes hsematocele exists coincidently with menorrhagia of
several months' duration. Intense ansemia is generally only observed where the
hsematocele is complicated with menorrhagia ; without this, its presence is com-
patible with the retention of a healthy colour of the face. 7. The growth of a
hsematocele is sometimes slow, sometimes very rapid. It may in a few days
attain the size of a man's head ; and in this case the symptoms are generally
those of an internal hemorrhage. 8. Some days after the emptying of a hsema-
tocele, the exudation acquires a penetrating odour, which may be removed by
careful injection of the cyst with warm water. 9. Menorrhagia occurring in
conjunction with a hsematocele soon ceases, as soon as the hsematocele is per-
fectly emptied. 10. Prolapsus of the vagina may be produced by hsematocele,
with or without the presence of pregnancy. 11. in the highest grade of antero-
uterine hsematocele, the tumour reaches downwards lower than the orifice of the
urethra, and upwards as far as the umbilicus. 12. The bladder and uterus are
generally pushed upwards by the tumour, more frequently forwards, rarely back-
wards and to the side. The direction of the displacement may be ascertained
by careful catheterization. A hsematocele projecting into the vagina is not
reduced in size when the bladder is emptied by the catheter. 13. Hematocele
may be induced by extra-uterine pregnancy, when apoplexy of the ovum and
extravasation of blood takes place. 14. Secretion of milk appears not to ac-
company hsematocele, unless pregnancy be also present. If there be lacteal
secretion in a case of hsematocele, when the uterus is evidently empty, there is
No. LXXXYII.— July 1862. 18

Progress of the Medical Sciences. [July

probably an extra-uterine preg'nancy. 15. Extra-uterine blood-tumours occur-
ring during pregnancy may fill nearly the whole pelvis, and, lying behind the
urethra, may produce the same troubles as vaginal cystocele or hernia of an
ovarian cyst into the vagina. 16. Exploratory puncture forms the only abso-
lutely sure means of diagnosis between ovarian tumours and uterine hsematocele.
— Banking's Abs., vol. xxxiv., from Wiener Med. Wochenschr., Aug. 31, 1861.

MEDICAL JURISPEUDENCE AND TOXICOLOGY.

77. Additional Experiments on the Poisonous Ejects of Coal Gas upon the
Animal System. — Dr. C. J. B. Aldis, in a paper read before the Royal Medical
and Chirurgical Society a short time ago (see No. of this Journal for April of
this year, p. 568), communicated the results of his experiments made with the
coal-gas as it issued from the main ; he has since (March 11th) narrated some
experiments made with common gas diluted with atmospheric air in different
proportions. The experiments were made with Mr. Henry Banister, on February
7 and 14, 1862. In the first experiment, common gas and atmospheric air, in
equal proportions, were administered to a rat placed under a glass vessel. The
head dropped in one minute, and it became insensible, with slight convulsion, in
one minute and a quarter; the respiration was hurried, the eyes staring, and
spasmodic jerking of the body, followed by death in two minutes and a half.
The post-mortem appearances were similar to those already described, except a
darkish patch on the anterior part of the pleura of the right lung, like that pro-
duced by smoke. The second experiment was made with one-fourth common
gas and three-fourths atmospheric air. The respiration of the animal became
hurried in three minutes, the head dropped in five minutes, and death occurred
in eleven minutes. During the autopsy, a smoky-looking spot was seen on the
pleura. In the third and fourth experiments, the proportion of gas to air was
one-fifteenth. The former experiment was not sufficiently prolonged to show
the deadly influence of the gas in this diminished quantity ; but in the latter
the rat soon began to pant, and the head fell in ten minutes, springing of the
body was observed, with twitching of the ear, followed by coma in seventeen
minutes. The eyes were open, the respiration became laborious in forty-one
minutes, when death ensued. The surface of the skull was intensely red ; the
brain congested ; the blood very fluid and bright-coloured ; the pleura of a
bright red colour, and the right side of the heart distended with darkish blood.

Dr. Hodgkin said that as illustrating the condition under which miners were
often unfortunately placed, the experiments were very valuable, but they did not
show whether the coal-gas acted as a poison, or whether the death might not be
due to the absence of oxygen. He (Dr. Hodgkin) then referred to some experi-
ments of the late Mr. William Allen. He placed animals in an atmosphere
containing hydrogen and oxygen. It was found that death took place, not be-
cause they were poisoned by hydrogen, but because they consumed the oxygen,
breathing at length hydrogen and carbonic acid.

Dr. Wynn Williams said that in the year 1857 he had had under his care two
cases of poisoning by coal-gas. One of the patients died. The patients were two
sisters, old women. They went to bed one evening between eight and nine, and
as they did not get up at the usual time next morning, their bedroom window
was broken open. They were both found to be unconscious. One of them re-
covered. She said that all she remembered was waking in the night, and hear-
ing her sister get up. Soon after this she became insensible, and remembered
nothing more. She suffered a great deal from muscular rheumatism, and after-
wards had rheumatic fever. The patient who died remained in a comatose
condition for fortj^-eight hours, and then became partially sensible; but in
three or four days she again became comatose, and occasionally violent, and at
length died. Dr. Williams said that at a previous meeting he had understood
that Dr. Kidd expressed an opinion that the effects of chloroform and coal-gas

1862.]

Medical Jurisprudence and Toxicology.

275

were alike. The symptoms in the case he had related were different to those
generally found in poisoning by chloroform. — Med. Times and Gaz., March 29,
1862.

78. Connection hetween Poisoning by PhospJiorus and Fatty Degeneration
of the Liver. — Dr. Lewin, of Berlin, has lately directed the attention of the
profession to the curious fact that there is an evident connection between
poisoning by phosphorus and fatty degeneration of the liver. He was led to
this discovery by finding in the published reports of cases of poisoning by
phosphorus, in which autopsies had been made, statements regarding an altera-
tion of the liver. He then experimented upon dogs and rabbits, and found that
we may, by administering small doses of phosphorus which do not immediately
kill, cause fatty degeneration of the liver, with destruction of the acini, that is,
a condition closely analogous to that which is found to exist in cases of acute
atrophy of the liver. He also discovered that poisoning by phosphorus pro-
duced a peculiar affection of the kidneys, and rendered the urine albuminous as
long as life continued.

These physiological experiments were soon afterwards shown to be perfectly
correct by a case of poisoning by phosphorus which occurred in the clinique of
Professor Frerichs, in the Charite Hospital. A servant girl committed suicide
by eating the tops of a thousand lucifers ; when brought into the Hospital she
suffered from icterus and enlargement of the liver ; the urine contained biliphgein
and albumen. She died shortly afterwards without having had much pain, and
no symptoms of a disturbance of the nervous system having been observable.
The post-mortem examination, which was performed with the greatest care,
showed that the blood was in a state of dissolution, it had the colour of cherry
juice, was very thin, and no coagula, and scarcely any globules were found in it.
The skin and the mucous membranes were suffused with blood, the liver was
greatly enlarged, and its edges blunt. On being examined by the microscope,
the acini appeared to be filled with fat to bursting. — Med. Times and Gaz.,
May 3, 1862.

79. Poisoning hy Aniline and by Nitro-Benzol. — George L., aged 16, was
brought to the London Hospital on June 8, 1861, in a state of insensibility.
The general surface of the body was pallid and cold ; the lips, buccal membrane,
face, and nails, were of a deep purple colour. The pulse was slow and scarcely
perceptible, and the apex beat of the heart very feeble. He had vomited several
times before admission, and was now just sufficiently conscious to complain of
pain and swimming in the head. He smelt strongly of coal-tar. It appeared
that he had been found in a state of insensibility in the interior of a vat used in
the manufacture of aniline, which he was engaged in scrubbing. All his clothes,
which ssvere strongly impregnated with the peculiar odour, were removed; he
was placed in a warm bed, and some hot brandy and water and a dose of cam-
phor and ether were administered. When the patient had rallied a little, his
body was well washed with soap and water, to prevent any further absorption
from impurities adherent to the skin. On the following day, the patient was
still rather blue, and complained of weakness, and his breath still smelt strongly
of aniline. These symptoms gradually passed off, and a few days afterwards,
being quite well, he left the hospital.

This is the first case of poisoning by aniline placed on record, and it differs
in many respects from the recent case of poisoning by nitro-benzol, which occur-
red at the same chemical works. Through the courtesy of Mr. Fletcher the
following facts have been ascertained concerning the death of the lad from nitro-
benzol : He was employed, it appears, in the laboratory, and finding that a
siphon did not act properly he thoughtlessly sucked through it some of the fluid
(nitro-benzol), which he wished to transfer from one vessel to another. He did
not, however, attach any importance to this act until some time afterwards, a
circumstance which shows that gastric uneasiness was not immediately pro-
duced.

Mr. Fletcher noticed in the morning that the lad did not look well, but. on
being questioned, the boy said that he felt " quite well, only sleepy." When he

2T6 Progress of the Medical Sciences. [Jnly

went home he told his mother that he felt " as though he were drunk." It was
then that he first mentioned his imprudence with the siphon. He ate very little
for dinner ; the stupor became gradually more profound till it was impossible to
rouse him, and he died at ten o'clock P. M., about twelve hours after swallowing
the nitro-benzol. It is stated that neither vomiting or convulsions occurred.

Dr. Letheby, under the order of the Coroner, made a post-mortem examina-
tion of the body, and his observations, about to be published, will be anxiously
desired by the profession. — Med. Times and Gaz., March 8, 1862.

80. New Mode of Detecting Minute Traces of Morphia. By M. Lefort, of
Paris. — It is often very necessary to determine whether a substance contains
certain alkaloids, and hence a process capable of accurately distinguishing be-
tween them has always been a desideratum. Lately, M. Lefort, a pharmaceutical
chemist in Paris, has established : 1st, that when organic matters decompose
iodic acid, the iodine set free is generally absorbed by caustic ammonia, and the
mixture is completely decolourized ; 2d, that, on the contrary, morphia, which is
decomposed by iodic acid with the production of a red or brown colour, acquires
a much deeper colouration on the addition of ammonia.

These reactions are very delicate, being capable of indicating the presence in
a solution of a ten-thousandth part of morphia. The experiment is very readily
performed by dipping unsized paper several times in the solution, and drying it
each time ; ultimately there is deposited upon the paper a quantity of solid
morphia, sufficient to give, in a very characteristic manner, the reactions of this
alkaloid with nitric acid, perchloride of iron, and finally with iodic acid and
ammonia. This method of procedure presents, particularly in medico-legal
investigations, the advantage over that which consists in experimenting on the
solutions themselves, of preserving the corpus delicti, modified, it is true, by the
chemical agents, but capable of being kept for a long time without alteration.
The reaction with the salts of the sesquioxide of iron presents, when unsized
paper is employed, this peculiarity, that the colour is no longer blue or green, as
in the case of the solution, but that it is always green, and that the shade is so
much the deeper, according as there is more of the alkaloid in proportion to
the salt of iron. The paper on which the reaction is obtained may be kept for
a long time without alteration. This reaction of the salts of the peroxide of
iron with morphia is the more important, as no other alkaloid behaves with
them in the same manner. — Ed. Med. Joicrn., December, 1861, from Gazette
Hebdomadaire, Nov. 1, 1861.

1862.]

277

AMERICAN INTELLIGENCE.

origijstal communications.

Case of Opium Poisoning in which Belladonna was successfully used
as an Antidote. By W. S. Duncan, M. D., of Brownsville, Pa. — At 7
o'clock A. M., on the 21st of May, 1862, Mrs. C, aged 38, swallowed with
suicidal intent two ounces of laudanum. I first saw her an hour and a
half after the poison had been taken; found her with flushed face, con-
tracted pupils, and stertorous respiration ; pulse 70, full and strong. She
was almost insensible to external impressions, and when aroused by violent
shaking and loud speaking immediately sank back into a comatose sleep.
A stomach-pump not being at hand, I administered, immediately, zinci sul-
phas, ipecac, pulv. aa gr. xx. This producing no effect in ten minutes gave
zinci sulphas gr. xii, ipecac, pulv. gr. xx. There being no effort at vomit-
ing in ten minutes more, gave antim. et potass, tart. gr. iii, which in ten
or fifteen minutes was followed by slight emesis. A half pint of warm
water was then given and the fauces freely irritated with a feather, after
which a pint of dark matter was ejected which smelled strongly of lauda-
num. During the next hour and a half she took tinct. belladonnas f^j in
divided doses. At 12 o'clock M., she was insensible to external impres-
sions of any kind ; pupils contracted to a mere point ; whole surface cool
and covered with clammy perspiration ; unable to swallow fluids ; counte-
nance pale ; pulse thready and feeble — almost imperceptible. Gave per
rectum ext. belladonnse gr. iii, warm water fjiss. 2 o'clock P. M. No
change. Repeat belladonna injection. Cold water to head, warm bricks
to feet, and whole surface rubbed with dry flannel. 4 o'clock. No percepti-
ble alteration. Repeat belladonna injection. Continue cold water to head
and warm bricks to feet. 6 o'clock. Surface dry, extremities warm. Other-
wise condition about the same. Repeat belladonna injection. 9 o'clock.
Breathing somewhat easier; pulse 100, with a little more force. No other
change, 12 o'clock, midnight. Still insensible ; whole surface warm and
dry. Ext. belladonnse gr. iii, warm water f^iss per rectum.

May 22, 2 o'clock A. M. Pulse 96, full and strong ; pupils slightly sen-
sible-to light; breathing more natural; pungent heat of whole surface.
Ext. belladonnae gr. ii, warm water f^j per rectum. Whole surface sponged
with cold water. 3 o'clock. Pupils slightly dilated and sensible to light ;
breathing nearly natural; patient begins to be restless, tosses her arms
about and turns frequently in bed ; occasional muttering ; answers ques-
tions but not always correctly. Half an hour later she started suddenly
up in bed and asked for a drink of w^ater. Pupils largely dilated ; pulse
90,. full and strong ; and patient complains of an intolerable itching over
the whole surface, which is warm and dry. Says she cannot see distinctly,
and " sometimes there are two candles where there should be one ;" nearly
rational, though when left to herself her mind seems to wander. Whole
surface sponged with soda bicarb, ^iss, aqua Oij. 10 o'clock A.M. Still
complains of the itching and dimness of vision ; pupils large ; tongue dry

278

American

Intelligence.

[July

and fauces red, but do redness of the skin, as is sometimes seen in belladonna
poisoning; has passed urine. R. — Hyd. chlor. mit. gr. x; jalap, pulv.
gr. xii. The cathartic failing to operate, at three o'clock an injection of
warm water was given ; in half an hour after the bowels acted freely and
the patient was well.

In addition to one ounce of tinct. belladonnae first given, twenty grains
of extract were administered per rectum.

I instituted no subsequent experiments to ascertain the efficacy of the
belladonna preparations used, though when consciousness returned the
patient was fully under the influence of the drug, and without some anti-
dote the dose of opium was surely sufficient to have produced death.

Clover-Hay Tea in Hooping- Cough. — Dr. Condie, of this city, informs
us that in consequence of seeing, in the recent medical journals, a notice of
the efficacy of a strong tea made from trifoil or clover-hay in allaying the
spasmodic cough of pertussis, he was induced to try it. He gave it in three
cases to children labouring under very severe attacks of the disease. His
only direction was that the tea should be made very strong, and, when cold,
given in large silver spoonful doses several times a day. In every one of
these cases the parents assured him that, very soon after commencing with
the tea, a marked amelioration of the spasmodic cough occurred. In one
of the cases it was entirely suspended after the use of the clover tea for
some forty-eight hours.

Prolonged Abstinence. — [The following interesting case of prolonged
• abstinence in a cat has been communicated to us by our friend, George
Ord, Esq. Mr. 0. is well known as an eminent naturalist, and as a most
careful and accurate observer. No doubt can be entertained that the animal
was wholly deprived of all food and drink for twenty-one days. Cases
in which life was maintained after even more prolonged deprivation of
nourishment, will be found related under the head of Abstinence, in the
American Cyclopaedia of Practical Medicine and Surgery : — ]

June 22, 1862. On the 15th of May, ultimo, whilst we were getting in
wood, a cat secreted himself in my cellar. The animal was not discovered
until the 5th of this month, when he was found, by his groans, lying in a
corner, and so exhausted for the want of nourishment that he could not rise.
I feel confident that there were neither rat nor mouse in the cellar, nor any-
thing to sustain life ; and certainly no fluid or water. I have carefully
sustained this animal, with fresh meat and milk, until the present time, and
he now appears to be perfectly recovered ; although for upwards of a week
he could not move about except in a tottering gait. For the first three or
four days I was compelled to support him when he was feeding. He is a
castrato, and is streaked like a tiger. The expressions of gratitude of the
poor animal for our kindness to him are remarkable.

Case of 3Ionstrosity. By L. W. Baker, M. D., of Berlin Cross Roads,
Jackson County, Ohio.

On the 28th of June last I was called to see Mrs. McC, who was
in the eighth month of her sixth pregnancy. Abortion had commenced
twelve hours before my arrival, and on examination I found the breech
• presenting. In about three hours the membranes had broken, and the
body was born leaving the face in the hollow of the sacrum, without an
incident occurring worthy of note or sufficient to excite my suspicions of

1862.]

Original Communications.

219

there being anything unnatural. At this time the heart was acting
strongly, but upon a return of the pains for the expulsion of the head, I
perceived a faltering in its action, and fearing compression of the cord, I
introduced my finger in the usual manner for bringing down the head, but
was somewhat disconcerted in not finding a mouth where I thought one
should be. I however succeeded in finding one, and soon brought the two.
faced creature into the world.

Its general appearance was much like that which was reported by Prof.
Meigs in 1851, but differed from it in having four eyes, two noses and
mouths all well formed and symmetrical. To outward appearances the
faces were much as if two perfect ones had been cut in two by a line
extending from about half an inch from the infra-maxillary symphysis
through the superior maxillary bone and orbital process of the malar of
the same side, and the two larger portions united together, which caused
the two faces to look nearly at right angles from each other, while the
facial axis of each, if extended, would have crossed about an inch and a
half below the chin. Two ears were perfect, but the other two were lost,
save a small tit-like projection looking from above downwards, and situated
in the line of union on a level with the superior border of the upper lips.
There were four palpebrse with a double os frontis and three fontanelles.
Beyond the corneal suture there were no additional bones that I could
define. The whole posterior portion of the head was large a«d well deve-
loped, a horizontal section of which would have been nearly circular, while
the upper portion was much of the sugar-loaf form, and the whole com-
bined appeared to be about one-third larger than a natural head.

The sex was intended to be that of a female ; the labia pudendi were
natural, but the clitoris was enlarged almost to the size of a penis.

The monster gasped twice, opening both mouths and all four eyes simul-
taneously, and after two short convulsions it expired. A post-mortem
was denied.

Syrup of Triticum Repens in Irritable Conditions of the Urinary
Bladder. By the Editor. — The attention of the profession has been lately
called by Mr. Henry Thompson, of London, to the remedial powers of an
infusion of Triticum repens in irritable conditions of the bladder. (See
No. of this Journal for January last, p. 21*1.) Having very recently had
under treatment two cases of this troublesome complaint, the sufferer in
one being a lady and in the other a gentleman, to both of whom we had
been giving the syrup of uva ursi with less relief than we had usually found
that remedy to afford, we determined to try the Triticum repens. With
this view we directed an apothecary to prepare a saturated infusion of this
plant by displacement, and then by the addition of a sufficient amount of
sugar to make it into a syrup. This syrup we directed our patients to
take in doses of a teaspoonful four or five times a day. After a few days,
both reported that this preparation had afforded them more marked and
speedy relief than the previous medicine had done, and they likewise consi-
dered it a much more agreeable remedy. The syrup we found, indeed, to
be quite pleasant to our taste, and we recommend it as a convenient and
efficacious mode of administering this article.

280

American Intelligence.

[July

DOMESTIC SUMMARY.

Case of Poisoning hy Laudanum — Belladonna used as an Antidote. — Dr.
James Blake records {Pacific Med. and Surg. Journal, April, 1862) the fol-
lowing case : —

" G. B., set. 4 years. Had been sick for three weeks from measles, followed
by pneumonia. Was taking a preparation of quinia and iron with nitric acid,
and for two days had been improving, although still very weak.

On the morning of April 8th, I was called to see him at 5.30 A. M., his
father informing me that he was fearful he had given him a teaspoonful of lauda-
num, by mistake, instead of his medicine. When I arrived I found him insen-
sible, not capable of being roused, breathing very heavily ; he had already taken
ten grains of ipecac, before I saw him, but now was incapable of swallowing ;
pupil contracted to a point ; skin warm ; pulse 100, rather small. After waiting
a short time, to see if he could be made to swallow some sulphate of zinc, I sent
for some of the fluid extract of belladonna, and going myself to get a stomach-
pump, I requested a physician who was in the house to administer three drops
with a little water, as an enema, as soon as it arrived, and to repe,at the dose in
twenty minutes, should the pupil still remain contracted. The medicine did not
arrive until near a quarter past six, by which time the breathing had become
quite stertorous, and the child was becoming black in the face.

" On returning at 7 A. M., I found the child quite sensible, wide awake, asking
for drink, and the only apparent effect of the laudanum was that he seemed
rather sleepy. I was informed that ten minutes after taking the enema the
breathing became more natural, the expression of the countenance improved,
and that twenty minutes after the injection he roused up and asked for water.
The child was so much improved that, although the pupil was still contracted,
the second enema had not been given.

"A further attempt was made to produce vomiting, by giving sulphate of
zinc, and warm water and mustard, but unsuccessfully; and, as the stupor
seemed to be again coming on, I gave a drop of the extract in water by the
mouth, and two teaspoonfuls of castor oil. The stupor still increasing, and
the hands and feet becoming cold, another enema, containing three drops of the
extract, was administered, the extremities being kept warm by artificial heat.
At this time, the respiration had fallen to eight in a minute, the lips becoming
dark. In five minutes after taking the enema, the respirations were twelve in a
minute, and in a quarter of an hour were sixteen, the expression of the face be-
coming more natural. The child could now be easily roused, took some drink,
and was constantly rubbing its nose ; pupils still contracted. Stupor again
came on, and another enema was given, with three drops of the extract, and,
being obliged to leave, I directed two drops of the extract to be administered
every half hour until the pupil should dilate.

" On returning at 11 A. M., I found the child evidently affected by the bella-
donna; face flushed ; skin moist; pulse soft, but full; respirations eighteen in
a minute. Three enemata had been administered. Consciousness had been
perfectly restored ; complained of dryness of the throat ; had taken some egg
and brandy. The pupil had expanded a great deal, but still rather small.
Mucus was collecting in the bronchial tubes and trachea, and seemed to inter-
fere considerably with breathing. There was constant movement of the tongue,
caused apparently by twitching of submental muscles. No attempt at coughing
was made, although the child was strong enough to sit up, and to change its
position, it appeared as if the reflex sensibility had been destroyed. Discon-
tinued the use of the belladonna, and gave enemata with turpentine and castor-
oil, until the bowels were moved.

"2 P.M. Flush had gone off the face; pulse not so full, about 100; pupils
more dilated, about natural. The bowels have not been moved, although two
enemata, with castor-oil and turpentine, have been given, and two with soap
and water. During the last half hour, has been more drowsy; respiration
twenty-four ; evidently considerable secretion in the air-passages, and no effort

18^2.]

Domestic Summary.

281

to cough; at present cannot swallow. Ordered enema, witli croton-oil and tur-
pentine ; but the child evidently sinking from asphyxia. The bowels were
moved at 3 P. M., but the child died asphyxiated at 4.40 P. M., or about thir-
teen hours after taking the laudanum.

" I have reported this case, although terminating fatally, in order to call the
attention of the profession to the use of belladonna as an antidote to poisoning
with opium, and, vice versa, of opium as an antidote in poisoning with belladonna.
From the marked relief afforded by the administration of the belladonna, and
from the power it exercised on each repetition in rousing the child from a state
of coma, it is evident that it exerts a specific influence over some of the worst
symptoms produced by opium. The return of insensibility, both mental and
organic, was well marked, and was renewed at each dose of the medicine. Un-
fortunately, the reflex susceptibility of the mucous membrane of the air-passages
to stimuli, seemed to be diminished, as the child made no effort at expectoration
after it was once fully under the influence of belladonna. Owing to the copious
secretion caused by the subsiding pneumonia, the air-passage soon became so
loaded as to prevent respiration. Had this not been the case, and had the child
possessed a little more strength, I have no doubt but that the case would have
terminated differently ; in fact, so far as the symptoms of opium poisoning were
concerned, they were entirely relieved. The quantity of belladonna administered
was not very large, about eighteen drops of Thayer's Fluid Ext. My object
was to give as little as possible, being afraid about expectoration."

On the Non-Shortening of the Supra and Infra-Vaginal Portion of the
Cervix Uteri. — Dr. Isaac E. Tayloe, Professor of Obstetrics, &c., in the Belle-
vue Hospital Medical College, has published {America7i Medical Times, June
14, 1862) some very interesting investigations relative to this subject.

"It is a conceded and recognized fact," he observes, "that great physiological
changes in the uterus take place during gestation, that its walls become thicker,
softer, and more elastic, and during this period that it undergoes no alteration of
shape, although its cavity is considerably enlarged. It is, however, supposed, and
in this most authorities agree, that the cervix uteri undergoes what is technically
called shortening, or ' the behaviour of the cervix during pregnancy ;' and that
at the termination of utero-gestation the vaginal portion no longer forms a
conical projection in the upper part of the vagina, but that it is then considered
as having merged or moulded itself into the body of the uterus, forming one
cavity. Much importance is usually attached in works of forensic medicine
and obstetrics to the changes of the cervix uteri, in relation to the time of
pregnancy, its colour, its softening, and its shortening.

" The progress of this shortening has been computed by the gradual disap-
pearance of its intra-vaginal portion. Thus it is held that at the sixth month
one-quarter is lost, at the seventh month one-half, at the eighth month three-
quarters, at the ninth month to have entirely disappeared.

" Entertaining entirely different views on this subject, I have presumed to dis-
sent from the opinions of these authors, not only that the neck expands from
above downwards, but from the opposite one that the changes occur from below
upwards."

The subject is one of great physiological and obstetrical interest, and has
many important practical bearings, and Dr. Taylor has endeavoured by careful
investigations to elucidate it.

Dr. T. states that " during a service of four consecutive months, in the Belle-
vue Hospital, as well as in the Island Hospital, in the spring and summer of
1861, and also during a short service in the fall and winter, in the presence of
the house staff and several medical gentlemen and students, not less than up-
wards of one hundred and fifty patients have been examined by the touch and
speculum, at various periods of gestation, from seven months to the full time,
and during the first stage of labour in some of the patients. Nearly all, how-
ever, were the completion of pregnancy." * * *

" The examinations of the patients were made by the touch, horizontal and
dorsal position, and by various kinds of specula — the glass, black-coated specu-
lum preferred — and the records taken by the house stafi", and several of the cases

282

American Intelligence.

[July

were delivered the same day, or one or two or three days after ; and in many
instances the infra-vaginal portion of the cervix was longer instead of being
shorter."

The following conclusions are drawn by Dr. Taylor from his investigations : —
" 1. The cervix uteri, supra and infra-vaginal portion, does not unfold or lose
itself during gestation in the body of the uterus, and the cervix uteri become
obliterated at the full term of pregnancy, as Baudelocque, Gooch, Dewees,
Meigs, Montgomery, Bedford, and others believe.

"2. That the cervix uteri is not lost or merged into the vagina, by dilating
from below upwards, and become obliterated at eight to eight and a half months,
as Stoltz, Chailly, and others believe, but remains of its natural length, and is
sometimes longer.

" 3. That the whole cervix uteri, supra and vaginal portion, remains intact
up to the full term of pregnancy, and sometimes during the first stage of labour.

"4. That the shortening, as it is termed, is only apparent to the touch, con-
sequent upon the ramollissement and physiological hypertrophy that take place
during gestation, the cellular tissue becoming infiltrated by the changes incident
to pregnancy, and hence its breadth is greater than natural, and softer.

"In multiparse, where laceration of the os uteri has taken place on one or
both sides, and the glands were also diseased, the labia are everted and the os
patulous, the same as is noticed in many cases of cervical leucorrhoea, and hence
the finger can be introduced at the seventh, eighth, or ninth month, to the in-
ternal OS, and touch the membranes of the child, and, should the cervix have
undergone a more perfect softening, the os and cervix may be dilated a half to
three-fourths of an inch in diameter, though the whole cervix remains, supra
and infra-vaginal portion.

" 5. That in primiparse, the finger cannot be introduced into the external os
uteri : but in very exceptional cases, it may reach half way through the cervix.

" 6. That the external os is always felt first, and not, as some have supposed,
the internal os.

" 7. " That the secretion of the cervix uteri, which forms the so-called plug, does
not remain to the full term, but is changeable from time to time.

" 8. That the more perfect the softening the shorter the labour.

" 9. That when labour sets in, especially in a primipara, the cervix (even if
obliterated, and the os the size of a five-cent piece) can be clearly defined from
the body, by the difference it presents to the touch of the thick, round, and soft
portion of the body, and the tense thin membranous neck, and os.

" 10. That after labour in primiparse, if the neck has not been lacerated, the
cervix uteri will return, supra and infra-vaginal portion, to its natural length
very soon, though it is patulous and soft.

" 11. That these propositions are also corroborated by cases where the com-
plete separation of the vaginal portion of the cervix has occurred, and which
could not have taken place if the neck was fully obliterated at term (case in
Belle vue Hospital), also in cases of excessive oedema of the cervix, where the
neck is one and a half to two inches in length.

" 12. That from the investigations made during life, at various periods of preg-
nancy, at full term, and during the first Tstage of labour, and on post-mortem
examinations, the cervix uteri does not undergo any shortening or expansion of
the supra or infra-vaginal portion, but retains its whole length, and only becomes
expanded or dilated at the commencement of labour, the cervix serving as an
intermediate channel, or canal, between the body of the uterus and the vagina ;
this dilatation is effected through the combined operation of the softened condi-
tion of the neck, and by the pressure of the liquor amnii and the descent of the
child's head or body, the internal os being the first to yield. The expansion
thus beginning slowly, tends downwards towards the external os, and then the
walls of the cervix are gradually expanded and unfolded for the passage or exit
of the child ; no better or more perfect illustration can be adduced, than the
gradual expansion of the horse's anus during an evacuation, and its contraction
after an evacuation occurs. Some of the cases of labour in the hospital have
illustrated the same facts ; during the first stage of confinement, while the mem-
branes have been protruded through the os tincse, only a half inch in diameter,
the child has been delivered soon after."

1862.]

Domestic Summary.

283

Body Transfixed hy a Bayonet ; Recovery. — Dr. B. J. D. Irvix, Medical
Inspector 4tli Division Army of OMo, U. S. A., relates [American Med. Times,
May 17, 1862) the following remarkable example of this : —

"'in the early part of February, 1861, the various tribes of Apache Indians,
inhabiting the mountainous regions of Arizona, broke into open hostilities
against the government, perpetrating atrocities and unheard-of cruelties upon
the unfortunate white settlers, and torturing their luckless captives in the most
barbarous and cruel manner. Unfortunate prisoners were starved, others tied
up for slow target practice, and some were hung up by the feet and broiled to
death by fires built beneath their subverted heads ! It was during the enact-
ment of this ferocious crusade, that the following interesting case came under
my supervision.

" A small party of our troops were hemmed in. in one of the gorges of the
Chirricahui Mountains, by superior numbers of Indians, who were endeavouring
to capture our slender force. We held some prisoners of theirs as hostages for
the safety of some citizens in their possession, whom we desired to exchange.
On a certain occasion, the prisoners in our possession made a simultaneous
attempt to break away from our guards. One robust athlete, aged about 25
years, was knocked down by the sentinel by a blow from a musket on the back
of the head, and held pinned to the earth hy a hayonet ivhich transfixed his
body. The weapon entered the abdomen in the anterior upper angle of the left
hypochondriac region, passed directly backwards and downwards, and made its
exit a little below the posterior corresponding space, about two inches from the
vertebral column. The victim was held in that position for some moments,
until succour arrived to secure him and his desperate associates. A paroxysm
of momentary weakness was all that appeared preternatural in him. The
amount of hemorrhage was very slight, and the man did not present any of the
symptoms to be expected from so serious a lesion. He was tied and placed on
his back ; kept strictly quiet, and the cold water dressing applied — snoiu-ivater
was used from necessity. The diet allowed was of the sparest kind. Not a bad
symptom appeared, and on the fowrth day the wounds were perfectly healed by
adhesive inflammation. He complained but little of any pain or distress, which
I attributed to the innate pride of his stoical character; being a brother of the
chief of his tribe, he held it beneath his dignity to manifest any external show
of physical or moral suffering. On the ninth day he walked to the place of
execution, where he, with five of his companions, was hung to the boughs of
two stately oaks, overshadowing the graves of some fourteen of our citizens,
whom the savages had treacherously and cruelly tortured to death while pri-
soners in their hands. As we were desirous of making a lasting example to
our treacherous foes, the bodies were allowed to remain suspended permanently,
which prevented my making a post-mortem examination of the body of the one
whose case I have described."

Inversion of the Uterus of Tliirteen Years^ Standing reduced hy a Novel
Method. — -Dr. E. Xoeggerath, of New York, relates [American Med. Times,
April 26, 1862) a case of this in a lady 38 years of age. in whom the accident
occurred in her first labour on the 16th of April, 1847. Two unsuccessful efi'orts
were made in 1848, to restore the uterus, and after this the treatment was re-
stricted to the use of astringent injections to control the flooding. In February,
I860, the patient was first seen by Dr. N., who, having satisfied himself by care-
ful examination of the existence of chronic inversion of the uterus, he proposed
to attempt to restore it, to which the patient reluctantly consented.

On the 4th of March, 1860, Dr. X. having placed the patient in the position
for lithotomy, and placed her under the influence of chloroform, first attempted
reduction by the method proposed by Dr. AYhite, of Buffalo. This failing, he
was about to desist from further attempts, when the idea struck him of trying a
different plan of manipulation. He applied his hand in such a manner that
the fore and middle fingers grasped the right section of the tumour ; while the
thumb was implanted on the left side at a point where the upper two-thirds of
its length met the lower one. In this manner, a pressure was exerted by the
thumb on the lateral border of the body of the womb, which pressure took an

284

American Intelligence.

[July

upward as well as a lateral direction, and resulted in the formation of an oblong
groove, the long diameter of which pointed below towards the left horn of the
uterine fundus, and upwards to the spot where the inverted and the non-inverted
portion met on the left side. The olDject of this first step of the operation was
to completely double up the uterine cavity, so that the right — now inner — wall
touched the left one. After this was completed, the dimpled portion was car-
ried upwards by the thumb, and in doing so it could be observed that the right
side of the upper section of the inverted cervix passed first of all through and
beyond the os uteri. During the progress of this manipulation, the right lower
section of the uterine body followed, and reassumed its normal position, while
the opposite part of the fundus continued to remain outside the os, only much
shortened and doubled up. As soon, however, as half of the tumour had disap-
peared inside the abdominal cavity, the intra-vaginal section slipped suddenly
out of my fingers, and the operation was completed. The entire manoeuvre was
performed in a shorter time than it takes me to give its description. The en-
trance of the last portion of the uterus was so complete, that I deemed it unne-
cessary to introduce a bougie into the restored uterine cavity, with a view of
preventing re-inversion.

" After the patient had recovered her senses, she felt very weak and nauseated,
in which condition she continued for the next twenty-four hours. Owing to a
slight feverish reaction, she was not able to leave her bed for a full week. The
operation checked the hemorrhage at once, and in its place she remarked a
moderate discharge of a thin serous liquid. Three weeks after the operation,
the menses reappeared, and lasted seven days, the loss of blood being consider-
ably less severe than it had been for many years back. A year afterwards,
w^ien I saw Mrs. Reaute for the last time, the position of the uterus was un-
changed ; pain, hemorrhage, leucorrhoea had disappeared, and the appearance
of the patient was considerably changed for the better.

Nitric Acid in Hooping Congli. — Dr. S. W. Noble highly extols [Chicago
Med. Journcd, Maj^ 1862) the efficacy of nitric acid in hooping cough. He used
the remedy during an epidemic of the disease in McLean County, 111., in 18.52-
53, with the most satisfactory results. The method of giving the acid is as
follows : He adds to a tumbler of sweetened water enough nitric acid to make it
pleasantly sour, and directs his patients to drink it /reel]/. He has given as
much as a drachm of the acid, in the twenty-four hours, to a child six months
old. He asserts that this remedy very materially shortens the duration of the
disease.

Seeds of the Cucurhifa Pepo, or PiimpMn, in Tcenia. — Dr. G. R. Patton, of
Cincinnati records {The Cincinnati Lancet and Observer) June, 1862) four
cases of taenia successfully treated by an emulsion of pumpkin seeds. One
patient was troubled with the Bothriocephalus latiis, the others with tcenia
solium.

Dr. P. says, that " of all the anthelmintics proposed for the extermination of
taenia, the seed of the ordinary pumpkin claims our first attention. It is inno-
cuous, inexpensive, readily procured, and by far the least disagreeable of all the
vermifuge medicines. Its power to dislodge large fragments of these entozoa
has never been questioned ; but it has not succeeded, in every instance, in
destroying them. This results evidently from discontinuing the remedy too
soon. By maintaining the treatment from four to six days (unless the head be
discovered with the fragments first passed), success would, doubtless, result in
all cases.

" The administration of castor-oil during its use is not to be recommended.
The emulsion itself is suSiciently laxative in large doses, if a light diet be strictly
enforced. By purgation we might defeat our end, by interfering with that inti-
mate contact of the remedy with the head of the parasite, necessary to the
production of its full toxicological effect."

Staphyloma of Cornea; Iridectomy; Suppuration of Globe. — Dr. Henry
D. NoYES, Assistant Surgeon New York Eye Infirmary, relates [American

1862.]

Domestic Summary.

285

3Ied. Times, May 10, 1862) the following case of this, which he justly remarks
is instructive in several points, and showing what may complicate the operation,
" Mary McG., set. 17, for many months suffering from granular conjunctivitis
with pannus of the cornese, came to the Infirmary in February. After two
months' treatment, consisting of general tonics, atropine in the eyes, and tr.
iodine to the forehead, the acute symptoms of keratitis passed away. Photo-
phobia, lachrymation, pain, congestion of the sclerotic disappeared, while the
opacity of the cornea began to clear up. No nitrate of silver was employed,
the corneal inflammation utterly forbidding, in my opinion, the employment of it
or of any irritant. The left cornea was in a state of total staphyloma, the
elevation not very large but deeply opaque, a ring of clearer substance remained
at the extreme edge of the cornea.

For the sake of reducing the staphyloma, as well as to take advantage of the
clear margin of cornea, I determined upon iridectomy. The section was made
at the lowermost part of the globe, the point of the straight lance knife entering
the sclera at one-eighth inch from the cornea, and pushed very obliquely through
into the anterior chamber. The stimulation of ether, and the manipulation of
the eye, induced extreme turgidity of the recently congested zone of vessels
surrounding the cornea. Through these distended vessels the knife penetrated,
and in consequence the bleeding was very free. It even required the liberal
use of sponges. The anterior chamber, when I was at last able to use the
forceps, and seize the iris, was full of blood. Bleeding was renewed upon cut-
ting off the bit of iris, and continued some minutes. The eyelids were therefore
left unstrapped. Severe inflammation followed, which in spite of leeches, and
paracentesis, etc. etc., culminated in rupture of the cornea by suppuration of
the globe. During the week while this process was going on, two smart hemor-
rhages occurred from the interior of the eye."

Polypus of the Ear successfully destroyed by the Persidphate of Iron. — Dr.
E. L. Holmes reports {Chicago Medical Journal, May, 1862) two cases of poly-
pus of the ear successfully destroyed by the persulphate of iron, which he used
in the following manner. He prepared small cylinders of the salt, about a quarter
of an inch in length, and scarcely a line in diameter, from a thick paste of the iron
and mucilage well rubbed together. Into a puncture, half an inch deep, which he
made in the tumour with a narrow knife, he introduced one of these cylinders.
On the next day the pain had not increased. On syringing the ear gently with
warm water, and drying the passage with tufts of cotton, he found the meatus
closed with a hard gray mass, which, on removal, proved to be a large portion of
the polypus firmly coagulated. Another cylinder was introduced in the same way
the next day with the same result. Subsequently he merely applied small quan-
tities of the salt to the polypus, keeping it in place with a bit of cotton pressed
firmly against it. This was repeated daily, the quantity of iron being decreased
as the deeper portion of the polypus was reached. This was soon completely
destroyed, and in a week or ten days two small lamina of bone exfoliated, and
the ulcerated surface of bone healed.

Three months after the termination of the treatment, there was no sign of a
return of the polypus.

After applying this salt several times to mucous membranes, and to surfaces
covered with the most delicate cuticle. Dr. Holmes, with reason, we think,
believes that there is little danger of injury to the adjacent tissues — either in
polypus of the ear, nose, or of the uterus — if the application is made with care.

286

American Journal of Med. Sciences.

JEFFERSON MEDICAL COLLEGE— 1862-63.

The Session will commence on Monday, the 13th of October, with a General Intro-
ductory Lecture by one of the Professors. The regular lectures will begin the day
after. The Session will terminate on the last day of February.

Robert M Huston M D / Emeritus Professor of Materia Medica and General
^ * > • •> Therapeutics.

Emeritus Professor of Obstetrics and Diseases of
Women and Children.

Charles D. Meigs,

M. D., I

Institutes of Medicine, ....

General, Descriptive and Surgical Anatomy,
Chemistry, ......

Institutes and Practice of Surgery,
Materia Medica and General Therapeutics,
Practice of Medicine, ....

Obstetrics and Diseases of Women and Children,

Demonstrator of Anatomy,

By Prof. RoBLET Duxglison, M. D.
Joseph Pancoast, M. D.
'* Franklin Bache, M. D.
Samuel D. Gross, M. D.
Thomas D. xMiTCHELL, M.D.
♦* S. Henry Dickson, M. D.

Ellerslie Wallace, M. D.

Clinics will be held regularly during September; and every Wednesday and
Saturday in October, and during the course, Medical and Surgical cases will be
investigated, prescribed for, and lectured on before the Class. During the year
ending March the first, 1862, a vast number of medical and surgical cases were
treated, and several hundred surgical operations were performed ; among them many
of the most important.

The lectures are so arranged as to permit the student to attend the clinics of
the Pennsylvania Hospital, and the Philadelphia Hospital.

On and after the 1st of October, the dissecting-rooms will be open, under the direc-
tion of the Professor of Anatomy and the Demonstrator.

FEES.

Matriculation, which is paid only once, $ 5

To each Member of the Faculty $15, 105

graduation, ........... 30

ROBLEY DUNGLISON, M.D.,

Dean of the Faculty.

BELLEYUE HOSPITAL MEDICAL COLLEGE— CITY OF
NEW YORK.
SECOND ANNUAL SESSION.

The Trustees and Faculty of this College announce with much gratification the ex-
traordinary success of the first session of instruction. The experience of that session
has fully confirmed the views and expectations which led to the establishment of the
College. The advantages of the plan of combining thorough didactic with demonstra-
tive teaching, by the union of a Medical College with the Bellevue Hospital, have been
practically exemplified; and the Trustees and Faculty appeal with confidence to the
members of the medical class, embracing many practitioners, in behalf of the success-
ful practical working of the new plan of medical teaching, inaugurated on an exten-
sive scale, by this College.

FACULTY.
ISAAC E. TAYLOR, M. D., President
AUSTIN FLINT, Jr., M. D., Secretary.
James R. Wood, M. D., Professor of Operative Surgery and Surgical Pathology — No.
2 Irving Place.

Fran-k H. Hamilton, M. D., Professor of Military Surgery, Fractures, and Disloca-
tions.

Lewis A Sayre, M. D., Professor of Orthopedic Surgery — No. 795 Broadway.
Alexander B. Mott, M. D., Professor of Surgical Anatomy — No. 209 Tenth Street.

American Journal of Med. Sciences.

287

BELLEVUE HOSPITAL MEDICAL COLLEGE— Continued.

Stephen Smith, M. D., Professor of the Principles of Surgery — No. 45 West Thirty-
Fourth Street.

Isaac E. Tatlok, M. D., 'i Professors of Obstetrics ) No. 13 West Twentieth St.
George T. Elliot, M. D., I and the Diseases of I Xo. 18 West Twenty-Ninth St.
B. FoRDYCE Barker, M. D., J Women and Children. J No. 70 Union Place.
Benjamin W, McCready, M. D., Professor of Materia' Medica and Therapeutics — No.

7 West Ninth Street.
Timothy Childs, M. D., Professor of Descriptive Anatomy — Everett House.
Austin Flint, M. D., Professor of the Principles and Practice of Medicine — No. 74

Union Place.

R. Ogden Doremus, M. D., Professor of Chemistry and Toxicology — No. 70 Union
Place.

Austin Flint, Jr., M. D., Professor of Physiology and Microscopical Anatomy — No.
74 Union Place.

Charles Phelps, M. D., Demonstrator of Anatomy, and Curator of the Hospital
Museum.

N. E. MosELET, M. D., Prosector to Chair of Surgical Anatomy.

Sylvester Teats, M.D., Prosector to Chair of Operative Surgery and Surgical Pathology.

A. W. Wilkinson, M. D., Assistant to Chair of Chemistry and Toxicology.

Arthur A. Shiyerick, M. D., Assistant to Chair of Principles and Practice of Medicine.

PRELIMINARY TERM.

The preliminary term will commence on Wednesday, September 17, 1862, and
continue to the beginning of the regular term, viz., four weeks. In addition to daily
instruction in the Bellevue and Blackwell's Island Hospitals, at least three lectures will
be given daily during this term, exclusively by members of the Faculty. The didactic
instruction during this term will embrace the following subjects: Surgical Affections
of the Breast and Testes, by Prof Wood; Surgical Affections of the Eye, by Prof.
Sayre; Amputations, by Prof. Mott; Surgical Dressings, by Prof Smith; Inflammation
of the Uterus, by Prof Taylor; The Symptoms, Signs, and Disorders of Pregnancy,
by Prof. Barker: Uterine Therapeutics, by Prof Elliot: Diet, by Prof. McCready;
Comparative Anatomy, by Prof. Childs ; Diagnosis of Diseases of the Heart, by Prof.
Flint ; Toxicology, by Prof. Doremus ; Anatomy and Functions of Glandular Organs,
by Prof. Flint, Jr.

REGULAR TERM.

The regular term will commence on Wednesday October 15, 1862, and end early in
March, 1863.

During the whole of the Session the student will have the opportunity of attending at
least two hospital clinical lectures daily. In addition to these, four didactic lectures
are given on every week day except Saturday. The didactic lectures are so arranged
as not to interfere with attendance in the Hospital wards. Ample time is allowed for
accompanying the visiting physicians, surgeons, and obstetricians in their daily rounds,
attending clinical lectures, witnessing surgical and obstetrical operations, and follow-
ing private courses, without compromising in any degree the regular didactic instruc-
tion. Clinical and Demonstrative teaching constituting the great feature of this Col-
lege, the arrangements are such as to render the immense resources of the Hospitals
available to the student to the fullest extent.

All the lectures in this College are given either in the Hospitals or in the College
building situated within the Hospital grounds.

The Bellevue Hospital receives annually from ten to twelve thousand patients, the
average number of cases under treatment during the winter being from ei^ht to ten.
hundred. Cases of all descriptions, excepting only the contagious eruptive fevers, are
received. The annual number of births in the Hospital is about five hundred. The
BlachcelVs Island Hospital, under the charge of the Medical Board of Bellevue Hos-
pital, contains usually about one thousand patients, a large proportion being affected
with chronic diseases. This Hospital contains always several hundred cases of syphilis.

In addition to the immense field of clinical instruction afforded by these Hospitals,
the student may avail himself of other resources for practical instruction contained
in the great metropolis.

288

American Journal of Med. Sciences.

BELLEVUE HOSPITAL MEDICAL COLLEGE— Continued.

Practical Anatomy, amply provided for by law, may be prosecuted to any extent
and without expense

Twenty-two resident Physicians and Surgeons are annually appointed on the recom-
mendation of the Medical Board of the Hospital, after an examination, and receive a
salary adequate to their support.

The fees for all the tickets for the session amount to §105, Tickets for one or any
number of the seven departments of instruction may be taken out separately. The
Matriculation fee is $5. The Graduating fee is §30. No additional fees are required
for Hospital tickets or anatomical material. Students who have attended two full
courses in other accredited schools receive all the tickets for $50, exclusive of the
matriculation fee. Students after two full courses in this College, or who have attended
one full course in this College, and one full course in some other accredited school,
are required to matriculate only. Graduates of other schools, after three years, are
required to matriculate only. Prior to the expiration of three years they receive a
general ticket for $50.

3?he requirements for graduation are the same as in other Medical Colleges of this
State.

Board and Lodging can be obtained in New York for from $3 to S5 per week.
The necessary expenses of attending a course of lectures in this College need not ex-
ceed $200.

For circulars or further information, address or apply to the Secretary of the
Faculty, Austin Flint, Jr., M.D., No. 74 Union Place, corner of Nineteenth Street
and Fourth Avenue, New York.

Students on arriving in the City are requested to report at once at Bellevue Hos-
pital, situated on the East River, between Twenty-sixth and Twenty-eighth Streets,
and inquire for the Janitor of the College, Mr. Edwin A. Ware, who will take pains
to aid them in securing comfortable accommodations without delay.

HARVARD UNIVERSITY.

MASSACHUSETTS MEDICAL COLLEGE.

Th.e annual course of Medical Lectures of Harvard University will commence at
the Massachusetts Medical College, in North Grove Street, Boston, on the first Wed-
nesday of November, 1862. The regular course will be as follows : —

Obstetrics and Med. Jurisprudence, by Professor D. Humphreys Storer, M. D.

Morbid Anatomy, ..." " John B. S. Jackson, M. D.

Clinical Medicine, ..." " Henry 1. Bowditch, M. D.

Anatomy and Physiology, . . " " Oliver W. Holmes, M. D.

Theory and Practice of Medicine, " " George C. Shattuck, M. D.

Surgery, . . . . . " " Henry .J. Bigelow, M. D.

Chemistry, ....." " John Bacon, M. D.

Materia Medica . . . . " " Edward H. Clarke, M. D.

Demonstrator, David W. Cheever, M. D.

Clinical, Medical, and Surgical Instruction will be given at the Massachusetts
General Hospital, with Surgical Operations.

Collateral special medical instruction will also be given at the Hospital by Lectures
and otherwise, by Drs. Bowditch, Abbot, and Ellis.

Abundant material is afforded for the study of Practical Anatomy. The Koom de-
voted to this department is open day and evening, and lighted by gas.

Fees for the Lectures, Q»80 ; Matriculation fee, $3 ; Graduation fee, §20.

Good Board can be obtained at $2 50 to $5 00 per week. Boarding places provided
on application to the Janitor at the College.

Students are requested, upon coming to Boston, to call upon the Dean.

D. HUMPHREYS STORER, Dean of the Faculty.

July, 1862. No. 132 Tremont Street, Boston.

[July aud Oct.]

THE

AMERICAN JOURNAL
THE MEDICAL SCIENCES

FOR OCTOBER 1862.

CONTRIBUTORS TO THIS VOLUME.

JOHN ASHHURST, Jk., M. D., Late Senior Resident Surgeon to Pennsylvania Hospital.
W. F. ATLEE, M. D., Surgeon to St. Joseph's Hospital, Philadelphia.
L. W. BAKER, M. D., of Berlin Cross Roads, Jackson County, Ohio.
J. H. BILL, M. D,, ^55^. Surgeon U. S. A.

FREEMAN J. BUMSTEAD, M.D., Assistant Surgeon to the New York Eye Infirmary.
E. P. CHRISTIAN, M. D., of Wyandotte, Michigan.
D. FRANCIS CONDIE, M. D., of Philadelphia.

S. HENRY DICKSON, M. D., Professor of Pract. Med. in Jefferson Med. College, Phi-
ladelphia.

W. S. DUNCAN, M.. J)., of Brownsville, Pennsylvania.
PLINY EARLE, M.D., of Leicester, Mass.

AUSTIN FLINT, M. D., Professor of the Principles and Practice of Medicine in the Belle-

vue Hospital Medical College, New York.
AUSTIN FLINT, Je,, M. D., Professor of Physiology and Microscopy in the Bellevue

Hospital Medical College, New York.
V. J. FOURGEAUD, M. D., of San Francisco, California.
HENRY HARTSHORNE, M. D., of Philadelphia.
ISAAC HAYS, M. D., of Philadelphia.

CHRISTOPHER JOHNSTON, M. D., of Baltimore, Maryland.

JOHN Gf. KERR, M. D., Surgeon to Medical Missionary Hospital, Canton, China.

C. C. LEE, M. D., of Philadelphia.

LEFT, M. D., of Philadelphia.

FREDERICK D. LENTE, M. D., of Cold Spring, New York.
J. AITKEN MEIGS, M. D., of Philadelphia.

W. F. NORRIS, M. D., Resident Physician to the Pennsylvania Hospital.

GEORGE ORD, Esq., of Philadelphia.

JOHN H. PACKARD, M. D., of Philadelphia.

W. S. W. RUSCHENBERGER, M. D., Surgeon U. S. Navy.

J. H. SALISBURY, M. D., of Newark, Ohio.

ALFRED STILLE, M, D., Physician to St. Joseph's Hospital, Philadelphia.

TO READERS AND CORRESPONDENTS.

The following works have been received : —

Pathological and Practical Observations on the Diseases of the Abdomen,
comprising the Diseases of the Stomach and other parts of the Alimentary
Canal, (Esophagus, Csecum, Intestines, and Peritoneum. By S. 0. Habershon,
M. D., Lond., F. E. C. P., &c. &c. &c. Second edition, considerably enlarged
and revised. London, John Churchill, 1862. (From the Author.)

The Use of Perchloride of Iron and other Chalybeate Salts in the Treatment
of Consumption. By James Jones, M. D., Lond. London, John Churchill,
1862. (Prom the Author.)

Haemorrhoids and Prolapsus of the Rectum : their Pathology and Treatment ;
with special reference to the application of Nitric Acid. With a chapter on
the Painful Ulcer of the Rectum. By Henry Smith, F. R. C. S., Assist. Surg.
King's Coll. Hosp. Third edition. London, John Churchill, 1862. (From the
Author.)

The Health of the Royal Navy considered, in a Letter addressed to the Rt.
Hon. Sir John S. Packington, Bart., &c. By G-avin Milroy, M. D., Med. In-
spector, &c. &c. London, 1862. (From the Author.)

A Practical Treatise on the Diseases of the Heart and Great Vessels, in-
cluding the Principles of Physical Diagnosis. By Walter Hayle Walshe,
M. D., &c. &c. A new American from the third revised and much enlarged
London edition. Philadelphia : Blanchard & Lea, 1862. (From the Publishers.)

Health : its Friends and its Foes. By R. D. Mussey, M. D., LL.D., late Prof,
of Anatomy and Surgery in Dartmouth College, N. H., and of Surgery in the
Medical College of Ohio, &c. &c. Boston : Gould & Lincoln, 1862. (From
the Author.)

Cases in Surgery. Gunshot Wounds. Plural Births. By J. Mason Warren,
M. D. (Communicated to the Boston Society for Medical Improvement.)
Boston, 1862. (From the Author.)

Dislocation of the Femur into the Ischiatic Notch ; Reduction by Manipula-
tion ; Death from Rupture of the Bladder ; Dissection of the Hip. By Joseph
C. Hutchinson, M. D. Albany, 1862. (From the Author.)

The Sanitary Condition of the Army of the United States. By Edward Jar-
vis, M. D., of Dorchester, Mass. (From the Author.)

Diet for the Sick and Convalescent. By E. Neal, M. D. Philadelphia, 1862.
(From the Author.)

Medical Testimony in regard to the proper Mechanical Treatment of Joint
Diseases. By H. G. Davis, M. D.

Caries of Elbow-Joint, Operation of Excision, with Recovery of Useful Arm.
By N. C. Husted, M. D. Albany, 1862. (From the Author.)

296

TO READERS AND CORRESPONDENTS.

Amputation of the Cervix Uteri. By A. K. Gardner, M. D. (Reprinted
from the Bulletin of the New York Academy of Medicine. (From the Author.)

Malignant Pustule in the United States. By A. N. Bell, M. D. Albany,
1862. (From the Author.)

Yariola : its Nature and Treatment. By Andrew Nebinger, M. D. Phila-
delphia, 1862. (From the Author.)

The Domain of Medical Police. By Louis Elsberg, M. D. New York,
1862.

An Address on the Life and Character of the late Charles Edward Isaacs,
M. D. By Joseph C. Hutchinson, M. D. New York, 1862. (From the
Author.)

Memoir of the Hon. John Miller, M. D., late of Truxton, Cortland County,
New York. By George W. Bradford, M. D. Albany, 1862. (From the
Author.)

Proceedings of the Academy of Natural Sciences of Philadelphia. April,
May, June, 1862.

Communications of the Rhode Island Medical Society for the year 1862.
Providence, 1862. (From the Society.)

Transactions of the Medical Society of the State of New York, for the year
1862. Albany, 1862. (From Dr. G. W. Bradford.)

Medical Communications, with the Proceedings of the Seventieth Annual
Convention of the Connecticut Medical Society, held at Bridgeport, May 28th
and 29th, 1862. New Haven, 1862.

Seventh Annual Report on the Births, Marriages and Deaths, in the city of
Providence, for the year 1861. By Edwin M. Snow, M. D., Superintendent of
Health and City Registrar. Providence, 1862. (From the Author.)

Seventh Annual Report of the Board of Trustees and Officers of the North-
ern Ohio Lunatic Asylum, to the Governor of the State of Ohio, for the year
1861. Columbus, 1862. (From 0. C. Kendrick, M. D.)

Report of the Western Sanitary Commission on the General Military Hospi-
tals of St. Louis, Missouri. Presented August 1, 1862. St. Louis, 1862.

Annual Report of St. Yincent's Hospital, under the care of the Sisters of
Charity for the year 1861. By J. J. Connolly, M. D., Resident Physician and
Surgeon. New York, 1862.

Report of the Surgeons of the New York Ophthalmic Hospital for the years
1860—61. New York, 1862.

The following Journals have been received in exchange : —

Annales Medico-Psychologiques. Redege par MM. les Docteurs Baillarger,
Cerise, et Moreau (de Tours). April, 1862.

Gazette Medicale de Paris. Le Redacteur en chef, Jules Guerin. May,
June, July, 1862.

TO READERS AND CORRESPONDENTS.

29Y

Gazette Hebdomadaire de M6decine et de Chirurgie. Le Redacteur en chef,
A. Dechambre. Nos. 17, 18, 19, 23, 25, 26, 27, 28, 29. (1862.)
Medical Times and G-azette. July, August, September, 1862.
Edinburgh Medical Journal. May, June, July, 1862.

The Medical Critic and Psychological Journal. Edited by Forbes Winslow,
M.D. July, 1862.

The British and Foreign Medico-Chirurgical Review. July, 1862.

The Glasgow Medical Journal. July, 1862.

The London Medical Review. May, June, July, 1862.

The Half-Yearly Abstract of the Medical Sciences. Edited by W. H. Rank-
ing, M. D., Cantab., and C. B. Radcltffe, M. D., Lond. January — June, 1862.

The Retrospect of Medicine. Edited by W. Braithwaite, M. D., and James
Braithwaite, M. D. January — June, 1862.

The Indian Annals of Medical Science. No. XV., 1862.

The Madras Quarterly Journal of Medical Science. April, 1862.

British American Journal. Edited by Archibald Hall, M. D. June, 1862.

American Medical Times. July, August, September, 1862.

The Boston Medical and Surgical Journal. Edited by F. E. Oliver, M. D.,
and S. L. Abbot, M. D. July, August, September, 1862.

The American Journal of Insanity. Edited by the Medical Officers of the
New York State Lunatic Asylum. July, 1862.

The Cincinnati Lancet and Observer. Edited by E. B. Stevens, M. D., and
J. A. Murphy, M. D. May, July, 1862.

The Chicago Medical Examiner. Edited by N. S. Davis, M. D. June, July,
1862.

Buffalo Medical and Surgical Journal. Edited by J. F. Miner, M. D. July,
August, September, 1862.

The Ohio Medical and Surgical Journal. Edited by the Professors of Star-
ling Medical College. July, Sept., 1862.

The American Medical Monthly. Edited by J. H. Douglas, M. D. July,
August, 1862.

The Chicago Medical Journal. Edited by Daniel Brainaed, M. D., and
J. A Allen, M. D. July, August, 1862.

The Pacific Medical and Surgical Journal. Edited by James Blake, M. D.
June, July, 1862.

The American Journal of Ophthalmology. Edited by Julius Homberger,
M.D. Yol. L, No. 2. New York, September, 1862.

The Cincinnati Medical and Surgical News. Edited by A. H. Baker, M. D.
July, August, 1862.

American Journal of Pharmacy. Published by authority of the Philadelphia
College of Pharmacy. Edited by Wm. Procter, Jr., Professor of Pharmacy in
Philadelphia College of Pharmacy. July, September, 1862.

298

TO READERS AND CORRESPONDENTS.

American Druggists' Circular and Chemical Gazette. August, September,
1862.

The Dental Cosmos. Edited by J. D. White, M.D., J. H. McQuillan, D.
D. S., and Geo. J. Ziegler, M. D. July, August, September, 1862.
The American Journal of Science and Arts. July, September, 1862.

Communications intended for publication, and Books for Review, should be sent,

free of expense, directed to Isaac Hats, M. D., Editor of the American Journal of the
Medical Sciences, care of Messrs. Blanchard & Lea, Philadelphia. Parcels directed
as above, and (carriage paid) under cover, to Messrs. Triibiier & Co., Booksellers,
No. 60 Paternoster Row, London, E. C. ; or M. Hector Bossange, Lib. quai Voltaire,
No. 11, Paris, will reach us safely and without delay. We particularly request
the attention of our foreign correspondents to the above, as we are often subjected
to unnecessary expense for postage and carriage.

Private communications to the Editor may be addressed to his residence, 1525
Locust Street.

All bemittances op money, and letters on the business of the Journal, should be

addressed exclusively to the publishers, Messrs. Blanchard & Lea.

The advertisement-sheet belongs to the business department of the Journal,
and all communications for it should be made to the publishers.

To secure insertion, all advertisements should be received by the 20th of the
previous month.

CONTENTS

AMEEICAN JOURNAL

OF THE

MEDICAL SCIENCES.

NO. LXXXYIII. NEW SERIES.
OCTOBER, 1862.

ORIGINAL COMMUNICATIONS.
MEMOIRS AND CASES.

ART. PAGE

I. Experimental ResearcTies into a new Excretory Function of the Liver ;
consisting in the Removal of Cholesterine from the Blood, and its Dis-
charge from the Body in the form of Stercorine. (The Seroline of Boudet.)
By Austin Flint, Jr., M. D., Professor of Physiology and Microscopy in
the Bellevue Hospital Medical College, New York ; Microscopist to
Bellevue Hospital. (Illustrated by three plates containing fifteen figures.) 305

II. Notes on Arrow Wounds. By J. H. Bill, M. D., Assistant Surgeon

U. S. A. (With three woodcuts.) 365

III. Inoculating the Human System with Straw Fungi, to protect it against
the Contagion of Measles; with some Additional Observations relating
to the Influence of Fungoid Growth in producing Disease and in the Fer-
mentation and Putrefaction of Organic Bodies. By J. H. Salisbury, M.D.,

of Newark, Ohio 387

lY. Cases of Opium Poisoning treated by Belladonna, with Remarks. By
William F. Norris, M. D., Resident Physician to the Pennsylvania Hos-
pital 395

Y. On Fracture of the Sternum. By John Ashhurst, Jr., M.D., late Senior
Resident Surgeon to Pennsylvania Hospital 406

YI. Some Experiments on Poisoning with the Yegetable Alkaloids. By
J. H.Salisbury, M.D. . 413

REYIEWS.

YII. A Practical Guide to the Study of the Diseases of the Eye : their
Medical and Surgical Treatment. By Henry W. Williams, M. D. Bos-
ton : Ticknor & Fields, 1862. pp. 317 441

YIII. Health and Disease as influenced by the Daily, Seasonal, and other
Cyclical Changes in the Human System. By Edward Smith, M. D., LL. B.,
F. R. S., Assistant Physician to the Hospital of Consumption and Diseases
of the Chest, Brompton ; Physician to the Dramatic College ; Correspond-

300

CONTENTS.

AET. PAGE

ing Member of tlie Academie des Sciences, Montpelier, and of the Natu-
ral History Society of Montreal. London : Walton & Maberly, 1861,
8vo. pp. 409.

Health: its Friends and its Foes. By E. D. Mussey, M. D., LL.D., late
Professor of Anatomy and Surgery at Dartmouth College, N. H., and of
Surgery in the Medical College of Ohio; Fellow of the American Aca-
demy of Arts and Sciences, etc. etc. Boston: Gould & Lincoln, 1862.
8vo. pp. 368 448

BIBLIOGRAPHICAL NOTICES.

IX. Transactions of State Medical Societies : —

1. Transactions of the Medical Society of the State of New York, for

the year 1862. 8vo. pp. 532.

2. Communications of the Rhode Island Medical Society, for the year

1862. 8vo. pp. 195.

3. Transactions of the Medical Society of New Jersey, 1862. Ninety-

sixth Annual Session. 8vo. pp. 116.

4. Transactions of the Medical Society of the State of Pennsylvania, at

its Thirteenth Annual Session, held in Philadelphia, June, 1862.
8vo. pp. 152 463

X. Reports of American Institutions for the Insane.

1. Of the United States Government Hospital, for the fiscal year 1859-60.

2. Of the Northern Ohio Lunatic Asylum, for the fiscal year 1860-61.

3. Of the Long Yiew Lunatic Asylum, for the fiscal year 1859-60.

4. Of the Western Asylum of Kentucky, for 1861.

5. Of the Iowa Hospital, for the year 1861.

6. Of the Wisconsin State Hospital, for 1860-61.

7. Of the New Hampshire Asylum, for the fiscal year 1860-61.

8. Of the Massachusetts Hospital, at Taunton, for the fiscal year 1859-60.

9. Of the Massachusetts Hospital, at Northampton, for the fiscal year

1859-60 483

XL A Practical Treatise on the Diseases of the Heart and Great Vessels,
including the Principles of Physical Diagnosis. By Walter Hayle Walshe,
M. D., &c. A new American from the third and much enlarged London
edition. Philadelphia : Blanchard & Lea, 1862. 8vo. pp. 420. . . 496

XII. The Health of the Royal Navy considered, in a Letter addressed to
the Rt. Hon. Sir John S. Packington, Bart., G. C. B., M. P. By Gavin
Milroy, M. D., F. R. C. P., Medical Inspector under the General Board of
Health from 1849 to 1854, Medical Commissioner to Jamaica in 1851, and
a Member of the Sanitary Commission of the Army in the East, in 1855-56.
8vo. pp. 70. London, 1862 497

XIII. Haemorrhoids and Prolapsus of the Rectum : their Pathology and
Treatment ; with special reference to the Application of Nitric Acid.
With a chapter on the Painful Ulcer of the Rectum. By Henry Smith,
F. R. C. S., Assistant Surgeon to King's College Hospital. Third edi-
tion. London, 1862. 12mo. pp. 141 504

XI Y. On the Diseases impeding Reproduction in the Male and Female :
being the Pathology and Treatment of Spermatorrhoea, Impotency, and
Sterility. By Marris Wilson, M. D., M. R. C. S E. London : Tallant &
Co. [The author reserves the right of translation.] 8vo. pp. 225. . 505

CONTENTS.

801

ART. PAGE

XY. A Medical Handbook, comprehending such Information on Medical
and Sanitary Subjects as is desirable in Educated Persons: with Hints
to Clergymen and Yisitors of the Poor. By Frederick William Head-
land, M. D., B. A., F. L. S., Fellow of the Royal College of Physicians, etc.
12mo. pp. 348. London, 1861. . . 506

QUARTERLY SUMMARY

OF THE

IMPROVEMENTS AND DISCOYERIES IN THE
MEDICAL SCIENCES.

FOREIGN INTELLIGENCE.
Anatomy and Physiology.

1. Absorbing Power of the Human
Skin. By Dr. Murray Thomp-
son. . . . . . .507

2. Researches on the Influence of
Culinary Salt and Colffee on the

PAGE

Metamorphosis of Tissue. By

C. Yoit 507

3. Calorific and Yascular Nerves
of the Sympathetic. By M.
Claude Bernard. . . . 508

Materia Medic a and Pharmacy.

4. Is Alcohol Food? By Dr. Tho-
mas Inman 508

5. Rennet Wine. By Dr. George
Ellis 510

6. Preparation of Oxygenated Wa-
ter, and its Therapeutical Use.

By Dr. Ozanam. . . . 511

7. Medical Properties of the Wild
Thyme [Thymus serpillum), and
its Use in Spasmodic Cough. By

M. Joset 511

8. Chemistry and Properties of
the Cytisus Laburnum. By Dr.

T. S. Gray 512

9. Iodide and Oxyiodide of Anti-
mony, and their Therapeutic
action. By Dr. Yan den Cor-
put 512

10. Professor Polli on Sulphites. 513

11. Glycerole of Tar (Tar Plasma).

By Mr. Brady 515

Medical Pathology and Therapeutics, and Practical Medicine.

12. Suspended Animation. By
Committee of Royal Medical and
Chirurgical Society. . . . 516

13. Two Cases of Extensive Arte-
rial Obstruction from Separated
Cardiac Yegetations, followed
by Gangrene and Death. By
Dr. Goodfellow. . . .518

14. Epidemic of Typhoid Fever
Dependent upon the Use of Im-
pure Water 518

15. Diabetes with Spinal Irrita-
tion. By Dr. E. A. Kunkler. . 520

16. Diphtheria and its Sequelae.

By Dr. James Begbie. . . 520

17. Influence of Temperature on
Yellow Fever. By Dr. Archi-
bald Smith 521

18. Clinical Researches upon Aus-
cultation of the Head. By
Henry Roger, M. D. . . 521

19. On the Transmission of Syphi-
lis by Yaccination. By M. Ri-
cord 525

20. Treatment of Agues by Cin-

302

CONTENTS.

PAGE

clioniae Disulphas. Mr. H, R.
Oswald 528

21. On the Treatment of Pneumo-
nia, with the Results of One
Hundred and Five carefully Re-
corded Cases. By Dr. J. Hughes
Bennett 529

22. The Therapeutics of Delirium
Tremens. By J. L. Ranking, Esq. 531

23. Delirium Tremens — Large
Doses of Tincture of Digitalis —
Cure. By M. F. Manifold. . 532

PAGE

24. Action of Quinia upon Phthi-
sis. By Dr. Richard P. Cotton. 533

25. Treatment of Acute Dysentery
by the Nitrate of Silver. By
Dr. Duclos 534

26. Treatment of Acute Rheuma-
tism, considered with regard to
the liability to Affections of the
Heart under different Remedies.

By Dr. Dickson. . . . 535

27. Veratria in Rheumatic Fever.

By M. Bouchut. . . .536

Surgical Pathology and Therapeutics, and Operative Surgery.

28. Iliac Aneurism Remedied by
Opening the Sac, and Tying the
Common Iliac, and the Internal
Iliac Arteries. By Prof. James
Syme 537

29. Ligature of the Common Iliac
Artery. Mr. E. R. Bickersteth. 538

30. Resection of the Elbow. By

M. Bauchet 541

31. Complete Resection or Extir-
pation of the Astragalus. By
Dr. Oscar Heyfelder. . . 541

32. Compound Comminuted Frac-
tures of the Skull. By Dr. A.
Wynn Williams. . . . 543

33. Old Dislocations and their
Treatment. By Mr. B. E. Brod-
hurst. 546

34. Inversion in Strangulated Her-
nia. By Mr. Furneaux Jordan. 548

35. Local Gangrene treated by
Oxygen Baths. ByM. Laugier. 548

36. Contributions to the Statistics
of Cancer. By Mr. W. M.
Baker 549

Ophthalmology.

37. Amaurosis Consequent on
Acute Abscess of the Antrum,
produced by a Carious Tooth.

By Mr. S. J. A. Salter. . . 550

38. Blepharo-Spasm. By Mr. W.
White Cooper 551

39. Paracentesis of the Cornea.

By Mr. Geo. Lawson. . . 552

40. Periorbitis. By Mr. W.White
Cooper 553

41. Epiphora. By Mr. W. White
Cooper 554

42. Intra-Ocular Effusions and the
Ophthalmoscope. By W. White
Cooper 554

43. Atropia Paper. ByMr. Streat-
field. 555

44. On the Advantages of having
Eye-Instruments Gilt (especially
some of those employed in Iris-
Operations), with a Note con-
cerning Non-Metallic Instru-
ments. By Mr. Streatfield. . 556

Midwifery.

45. Turning in Cases of Dispro- | Hours after Delivery. By Mr.
portion between the Foetal Head Charles Cowan. . . . 557
and the Pelvis of the Mother. 47. Vessels Concerned in the Pro-

By Dr. M'Clintock. . . . 556 duction of Phlegmasia Dolens.

46. Inversion of the Uterus oc- By Dr. Tilbury Fox. . . . 558
curring Spontaneously Eighty

CONTENTS.

303

Hygiene.

PAGE

48. Influence of Railway Travelling on Public Health. .... 559

Medical Jukisprudence and Toxicology.

PAGE j 50. Strychnia Poisoning. By M.

49. Poisoning with Upas Tieut6. . 561 1 Duriau. ..... 562

AMERICAN INTELLIGENCE.

Domestic Summary.

Injury of the Arm common to
Children of from one to four
years of age. By Dr. R. M.
Hodges 563

Acute Chorea treated with Whis-
key. By Dr. A. Clark. . . 566

The Liver in Cholera Infantum.
By Dr. J. Lewis Smith. . . 566

Oakum as a Substitute for Lint in
Gunshot and other Suppurating

Wounds. By Dr. Lewis A.
Sayre. . . . . .566

Experiments on the Formation of
Infusoria in Boiled Solutions of
Organic Matter, inclosed in Her-
metically Sealed Yessels, and
supplied with Pure Air. By Dr.
Jeffries Wyman. . . . 567

Singular Case of Hernia. By Prof.
Parker. . . , , , 567

Am. Journ. Med. Sci., vol. xliv. PLATE I Y.

Fig. 11. Fig. 12.

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES

FOR OCTOBER 1 8 6 2.

Art. I. — Experimental Researches into a new Excretory Function of
the Liver; consisting in the Removal of Cholesterine from the Blood,
and its Discharge from the Body in the form of Stercorine. (Tlie
Seroline of Boudet.) By Austin Flint, Jr., M. D., Professor of Phy-
siology and Microscopy in the Belle vue Hospital Medical College, New-
York ; Microscopist to Bellevue Hospital. (Illustrated by three plates
containing fifteen figures.)

''La Cholesterine du sang est elle un de ces prodidts destines a Hre expulses
de V6conomie, et, par consequent, depourvus d' action immidiate sur Veconomie
ellemtme? Sa destination est tout d fait incojinue." Traite de Physiologie,
par F. A. Longet. Paris, 1861. Tome i. p. 488.

This sentence, which is taken from the most elaborate treatise on phy-
siology in any language, published at the centre of physiological science,
in 1861, expresses the state of our knowledge with regard to the function
of cholesterine, Cholesterine was discovered in 1Y82, by Poulletier de la
Salle, in biliary calculi, and was detected upwards of thirty years ago in the
blood by Denis ; but since then, with the exception of researches of a purely
chemical nature into its properties, our knowledge with regard to it has
not advanced. Its chemical history even, is far from perfect ; while its
physiological history is unknown. In 1833 Boudet discovered a substance
in the blood which he called Seroline ; a principle having many characters
in common with cholesterine, but heretofore interesting merely as a curious
proximate principle, found in excessively minute quantities in the serum
of the blood only (whence its name) ; too minute, indeed, for ultimate
analysis. Its function was as obscure as that of cholesterine. In examin-
ing the literature of these two substances, we find that cholesterine is fre-
quently not treated of in systematic w^orks on physiology. Seroline is sel-
No. LXXXYIII.— Oct. 1862. 20

306 Flint, Jr., 'New Excretory Function of the Liver, [Oct.

dom even mentioned. Their function has been so obscure and apparently so
unimportant, that theories with regard to it have not been advanced, and
the highest chemical authorities, in speaking of their office in the economy,
simply say of one, as of the other, that it is unknown. In the Chimie
Anatomique, by Robin and Yerdeil, we find cholesterine summed up in these
words : —

" Le role phi/siologique qu'elle remplit dans VSconomie est egalement in-
connu."

Of seroline, the same authors say : —

" On ne sait pas comment se forme la seroline, ni quel est son role pliysiolo-
gique.''

Though the physiology of these substances is thus obscure, though
chemistry has thus far done but little for their history, and physiology
nothing, certain facts with relation to them would seem to indicate that
they are not unimportant in the economy. Cholesterine is found in the
blood, bile, liver, nervous matter, crystalline lens, meconium (not in the
feces, as incorrectly stated by authors), besides in a number of morbid pro-
ducts. It is found in these situations constantly ; it appears in the blood
as soon as that fluid is found, and continues to the end of life. Its quan-
tity in the blood is increased in certain diseased conditions, and dimin-
ished in others, Seroline has been said to exist constantly in the blood,
though, till now, it has never been discovered in any other situation. It,
like cholesterine, is a constant principle, they having many chemical cha-
racters in common. Their function is definite ; it is important ; and, if
the writer do not exaggerate this importance in the enthusiasm of explor-
ing a hitherto absolutely uncultivated field, a knowledge of the functions
of these substances will be of incalculable value to the practical physician ;
and the path thus opened by physiology will lead to a great field for patho-
logical inquiry. What the discovery of the function of urea ho.s done for
diseases luhich now come under the head of uremia, the discovery of the
function of Cholesterine may do for the obscure diseases ichich may
hereafter be classed under the head of Gholesteremia.

It is not surprising that the function of substances — which have been
isolated with great difficulty, which have never been found in any of the
excretions, which exist in quantity so small, that their investigation
seemed to belong especially to the chemist, physiologists having been dis-
couraged, perhaps, from studying them — should be thus obscure. But it is
surprising that that important fluid, the bile, the product of the largest
gland in the economy, and the one most constantly found in the animal
scale, should be so little understood. This has been regarded by some as a
simple excrement, and by others as not an excrementitious, but a digestive
fluid, and so much labour has been expended by physiologists in endeavours
to settle this point, that no one has pretended to give an account of its excre-

1862.] Flint, Jr., New Excretory Function of the Liver. 30t

mentitious function, if it have any, and researches into its digestive function
have left us almost entirely in the dark. Blondlot reported an observation
on a dog which lived for five years with a biliary fistula diverting, as it is
stated, all the bile from the intestines and discharging it from the body.
The animal presented no untoward symptoms, died a natural death, no
bile found its way into the intestines, but it was all discharged. According
to this observation, the bile would appear to be purely an excrement.
Schwann, and Bidder and Schmidt, in a large number of experiments, never
succeeded in keeping a dog operated on in this way for more than a few
weeks ; they all died with evidences of inanition. The bile, according
to these observations, is concerned chiefly in nutrition ; and as it is poured
into the upper part of the digestive tube, it is important, probably, in
digestion. But Bidder and Schmidt do not satisfy us what its digestive
function is ; nor does Blondlot say what principle is excreted by it, nor
what would be the result of its suppression.

Aside from a few isolated facts, interesting enough, but indicating nothing
definite, this is all we know of the function of the bile. But what physi-
ologist does not feel this hiatus in his science; or what practical physician
does not feel and know the importance of the function of the bile ! It
needs no inquiry into natural history, showing the universality, almost, of
the liver in the animal scale, to impress upon the physician at the bedside
the importance of the bile. A patient is suffering under an obscure ailment,
which he may call biliousness or derangement of the liver, and which, in some
unexplained way, is relieved by a mercurial purge. The practitioner knows
that the bile-secreting function of the liver is important, but does not learn
it from the physiologist. Every practitioner must feel that the liver has a
function which must be explained him by the physiologist, before he can
avoid treating a large class of diseases empirically.

The bile has an important excretory function, which is liable to many
disorders ; and this function the writer hopes to be able, in the present
article, to describe.

It will be seen by the preceding remarks that the physiological history
of the bile remains to be written. The subject is too interesting and
important not to engage the mind of the experimental physiologist. It is
difficult at first sight to harmonize statements, to which reference has just
been made, of experimenters, equally entitled to consideration, which are
diametrically opposed. But of course the philosophical method of studying
the bile is first to settle whether it be excrementitious or recrementitious.
If the former, what substance is excreted, and where is it formed ? If the
latter, what function does it perform in any of the processes of nutrition.
With the view to harmonize, if possible, in my own mind, the opposite
statements of Bidder and Schmidt, and Blondlot, I attempted some time
ago to establish biliary fistulas in dogs. The first experiments were made
in New Orleans in the winter of 1860-61; but were all of them unsuc-

308 Flint, Jr., New Excretory Function of tlie Liver. [Oct.

cessful, no animal surviving the operation more than three days. The
experiments were discontinued at that time, but were renewed in the winter
of 1861-62 at the Belle vue Hospital Medical College. After a number
of trials which were no more successful than those made the previous win-
ter, I succeeded in performing the operation with considerable rapidity and
with very little disturbance of the abdominal organs, and in one animal
the success was complete.

Exp. 1. The operation was performed by making an incision into the
abdomen in the median line just below the ensiform cartilage, about three
inches in length. The edge of the liver was carefully raised, the bile duct
isolated, and two ligatures applied, one next the duodenum and the other
near the junction of the ductus choledochus with the cystic duct, the inter-
mediate portion being excised. The fundus of the gall-bladder was then
drawn to the upper part of the wound, an incision made in it of about an
inch in length, the bile evacuated, and the edges attached to the skin by
points of the interrupted suture. The wound was then carefully closed
around the opening into the gall-bladder.

This is nearly the proceeding recommended by Blondlot, who prefers,
however, to operate while the animal is fasting, as the gall-bladder is then
distended and can be more easily found. I have preferred to operate after
feeding, when the gall-bladder is comparatively empty, as there is no great
difficulty in finding it, and in evacuating its contents less bile is apt to find
its vfay into the peritoneal cavity, which is one of the causes of the intense
peritonitis which follows this operation.

The animal ate well the day after the operation, the bile flowed freely
from the fistula and was entirely cut off from the intestine, as shown by
post-mortem examination. No symptoms supervened except those pro-
duced by the diversion of the bile from its normal course. This operation
was performed on the 15th of November, 1861, and the animal lived thirty-
eight days.

In no observation that I have found recorded has the animal been so
free from inflammation consequent upon so serious an operation ; and this
seemed a most favourable opportunity of determining whether an animal
could live with the bile shut off from the intestinal tube and discharged by
a fistula. In this case the animal gradually lost flesh and strength, his
appetite becoming voracious, until finally he died of inanition; the obser-
vation agreeing in every important particular with the experiments of
Schwann, and Bidder and Schmidt.

Exp. 2. This experiment was undertaken to ascertain, if possible, the
entire quantity of bile secreted in the twenty-four hours. A fistula was
made into the ductus communis choledochus, the duct being divided and a
silver tube introduced. The experiment did not succeed in the point of
view in which it was undertaken, and about forty-eight hours after the
operation, the tube dropped out. After the removal of the tube the bile
ceased to flow externally, and the animal did not appear to suffer any bad
effects from the experiment. Thirty days after the operation, the animal
having entirely recovered, he was killed by section of the medulla oblongata,
and the parts carefully examined. The post-mortem examination I trans-
cribe from my note book.

"On post-mortem examination the liver was found adherent to the dia-

1862.] Flint, Jr., New Excretory Function of the Liver. 309

phragm over the greater part of its convex surface. There were evidences
of limited inflammation over the duodenum. The liver itself was normal.
Upon opening the duodenum, the papilla which marks the opening of the
ductus communis choledochus was normal in appearance. A small silver
stilet was introduced into the duct. For a long time it was impossible to
find any communication between the upper part of the duct and the intes-
tine; but at last, after patient searching {knowing that no bile was dis-
charged from the body and that it was absolutely certain that a communi-
cation existed with the duodenum), a communication was found. In
Blondlot's case there probably was a communication re-established which
escaped his observation."

In the remarkable observation reported by Blondlot, in which the animal
survived for so long a period, the success is attributed to the fact that the
dog was prevented from licking the bile as it flowed from the fistula, Blond-
lot stating that as soon as the animal was prevented from licking the bile,
nutrition began to improve. Anxious to carry out all the precautions
which had been adopted, I so muzzled the animal in Exp. 1, covering the
lower part of the muzzle with oiled silk, that it was impossible for him to
swallow a drop of the bile. This muzzle was kept on till the death of the
animal, but the proceeding had no effect on his nutrition. The bile flowed
so freely from the fistula that all the lower part of the animal was covered
with it. It was not, however, until I made the post-mortem examination
in the second experiment that I was able to see the difficulty which I had
experienced in harmonizing the observations of the different experimenters
I have quoted. In the lower animals — in dogs, at least — ducts have a
remarkable tendency to re-establish themselves. Any one who has operated
much upon the glands can hardly fail to have noticed this fact. The pan-
creatic duct, for example, after having been divided and a tube introduced,
becomes invariably re-established after the simple removal or dropping out
of the tube. It was so with Exp. 2, in which the tube dropped out of the
bile duct. The duct undoubtedly became re-established, for no bile flowed
externally for nearly a month,' the animal enjoying perfect health, and the
fluid necessarily being emptied into the intestine ; yet it was with the greatest
difficulty that the communication could be found with the probe, and it was
only after long searching, knowing that there must be a communication,
that it was discovered at all. Taking into consideration the great difficulty
I had in finding the passage in this instance, and after having carefully
examined the case reported by Blondlot, I have concluded that a commu-
nication existed in his experiment which escaped observation, but by means
of which a large quantity of bile found its way into the intestine.''

' An account of this experiment is to be found in an article -entitled "Essai st(?'
les Fonctions du Foi et de ses annexes par N. Blondlot.''^ 1846. The post-mortem
examination of the animal, made more than five years after the establishment of
the fistula, was published in a little memoir complementary to the preceding,
entitled ^^InutiliU dela Bile dans La Digestion.'''' 1851. It was not contemplated to

310 Flint, Jr., 'New Excretory Function of the Liver. [Oct.

Witli regard to the digestive function of the bile, it is sufficient to state
here that the experiments which I have made on this subject have led me to
believe that this fluid has an important office in connection with the func-
tion of digestion — one, indeed, w^hich is essential to life. The nature of its
office, however, is not understood, and can only be settled by a long and
carefully executed series of experimental researches which would probably
involve the whole subject of digestion. This I hope to be able to present
in another paper. There is, however, another function of the bile entirely
distinct from the preceding. It is the separation from the blood of the
cholesteriue, an excrementitious substance, which is formed by the destruc-
tive assimilation of certain tissues of the body. Though not discharged
from the body as cholesteriue, it being first changed into another substance,
it is separated in that form from the blood and poured into the intestine
by the ductus communis choledochus. This new excretory function of the
bile will form a great part of the subject of this paper; the re'crementitious
function, which is necessary to complete the physiological history of this
fluid, being deferred.

We will find the cholesteriue to be the most important excrement sepa-
rated by the liver, as the urea is the most important one separated by the
kidneys; and the study of this substance will necessarily involve the depu-
rative function of the liver. I will therefore begin with the cholesteriue,
and endeavour to show where it is formed in the economy, by following the
blood in its passage through various organs. This will necessarily involve
a description of the chemical processes which have been employed in its
extraction. I will then endeavour to show where the cholesteriue is removed
from the blood, by the same method of investigation. The next step will
be to follow it out of the body, and study the change which it undergoes in
its passage through the alimentary canal. Having described the process of
formation in the tissues, separation from the blood by the liver, and final
discharge from the body, I will endeavour to show, finally, the effects of
interruption of this function of the liver upon the economy. This will lead
us into pathology, and a host of diseases will arise which maybe dependent
on a disturbance of the excretory function of the liver. We will be enabled
to draw the line more closely between conditions in which there is resorp-
tion simply of the innocuous colouring matter of the bile, and those diseases
in which there is a failure to separate the excrements from the blood.
These conditions, it is well known, are widely different as to gravity, and
the distinction between them is of great importance. The latter condition,
characterized by the retention of cholesteriue in the blood, will be treated
of under the name of Cholesteremia.

enter into a full discussion of the views of Blondlot and others on the uses of the
iDile in digestion. That subject will be taken up in another paper in which the
digestive properties of the bile will be mainly considered. In this connection it is
proposed to take up only the excrementitious function of the bile.

1862.] Flint, Jr., New Excretory Function of tlie Liver. 311

Cholesterine.

Chemical characters. — Cholesterine is a non-nitrogenized substance,
having all the properties of the fats, excepting that of saponification with
the alkalies. Its chemical formula is usually given as C^^H^^O. It belongs
to a class of fatty substances which are non-saponifiable, which have been
grouped by Lehmaun under the name of lipoids. This class is composed
of cholesterine and seroline, which are animal substances ; castorine, from
the castoreum, and ambrein, from amber. To this he adds a substance
discovered in a uterine tumour by Busch, called inosterine. Cholesterine is
neutral, inodorous, crystallizable, insoluble in water, soluble in ether, very
soluble in hot alcohol, though sparingly soluble in cold. It burns with a
bright flame, but is not attacked by the alkalies, even after prolonged
boiling. When treated with strong sulphuric acid, it strikes a peculiar red
colour, which is mentioned by some as characteristic of cholesterine. I
have found that it possesses this character in common with seroline.^

Forms of its crystals. — Cholesterine may easily and certainly be recog-
nized by the form of its crystals, the characters of which can be made out
by means of the microscope. They are rectangular or rhomboidal, exceed-
ingly thin and transparent, of variable size, with distinct and generally regu-
lar borders, and frequently arranged in layers with the borders of the lower
ones showing through those which are superimposed. This arrangement
of the crystals takes place when the cholesterine is present in considerable
quantity. In pathological specimens they generally are few in number, and
isolated. The plates of cholesterine are frequently marked by a cleavage
at one corner, the lines running parallel to the borders ; frequently they
are broken, and the line of fracture is generally undulating. Lehmann
attaches a great deal of importance to measurements of the angles of the
rhomboid ; according to this author, the obtuse angles are 100° 30^ and
the acute 30'. I have lately examined a great number of specimens of
cholesterine, extracted from the blood, bile, brain, liver, and occurring in
tumours, and am confident that the crystals have no definite angle. Fre-
quently the plates are rectangular, and sometimes almost lozenge-shaped.
It is by the transparency of the plates, the parallelism of their borders, and
their tendency to break in parallel lines, that we recognize them as formed
of cholesterine. Lehmann seems to consider the tablets of this substance as
regular crystals, having invariable angles. From examination during crys-
tallization, I am disposed to think that they are not crystals, but fragments
of micaceous sheets, which, from their extreme tenuity, are easily broken.
In examining a specimen from the meconium, which I extracted with hot
alcohol, I was able to see a transparent film forming on the surface of the

1 This reaction of the seroline is mentioned by Berard, in the " Cours de Phy-
siologie,^^ tome iii. p. 117.

312 Flint, Jr., New Excretory Function of the Liver. [Oct.

alcohol soon after it cooled ; this, on microscopic examination, in situ,
disturbing the fluid as little as possible, was found to be marked by long
parallel lines. When the fluid had partially evaporated, it became broken and
took the form of the ordinary crystals of cholesterine, but they were larger
and more regular. The beauty of the tablets at this stage could not be ade-
quately represented. They were exceedingly thin, and regularly divided into
delicate plates, with the characteristic corner cleavages of the cholesterine;
and, as the focus of the instrument was changed, new layers, with different
arrangement, were brought into view. I have attempted to give an idea
of the form of these tablets in Fig. 1 ; but it is, of course, impossible to
represent their pale, but beautifully distinct borders. As has been remarked
by Robin, the borders of these crystals can be but imperfectly imitated by
a line ; there is no line in the object itself, but the edge shows where the
tablet ceases. (See Fig. 1.)

The crystals are generally colourless, but when present in coloured fluids,
may take a yellowish tint, or even become very dark. They may still be
recognized, however, by the characters of form just described.

Crystals of cholesterine melt at 293° Fahr., but are formed again when
the temperature falls below that point. According to Lehmann, they
may be distilled in vacuo at 680° without decomposition. The determina-
tion of the fusing point is one of the means of distinguishing it from sero-
line, which fuses at 90° 8'.

Situation of the cholesterine. — Most authors state that the cholesterine
is found in the bile, blood, liver, brain and nerves, crystalline lens, meco-
nium, and the fecal matter. I have found the cholesterine in all these
situations invariably, excepting the feces, where it was seen but once after
a number of examinations ; and in studying the works of those who have
investigated this substance, I can find no one who has found it in the nor-
mal feces. It is found in large quantities in the meconium, from which,
perhaps, it is most easily extracted in a state of purity, and has been
extracted from the feces of animals in a state of hibernation ; but though
it may occasionally be found in the feces in disease, and in animals after
long fasting, I am confident that it never occurs in the ordinary conditions.
The analysis of the fecal matter is so unattractive, that it has been very
much neglected by chemists ; and until a few years ago, when an elaborate
analysis was made by Marcet, to which reference will hereafter be made, the
analyses of Berzelius formed nearly all our data on this subject. Choles-
terine forms the greater part of biliary calculi, which indeed consist gene-
rally of nothing but cholesterine, colouring matter, and mucus. It is found
in a large number of morbid deposits. Few cases of cancer are examined
without discovering tablets of cholesterine. It is very abundant in encysted
tumours. According to Robin, atheromatous deposits, which are found in
the middle coats of the arteries, are often composed of cholesterine. It
sometimes forms distinct tumours or deposits in the substance of the brain.

1862.] Flint, Jr., New Excretory Function of the Liver. 313

I lately had an opportunity of examining a tumour from the brain, at the
Bellevue Hospital, which consisted of nearly pure cholesterine. It has often
been found in the fluid of hydrocele, in the fluid of ovarian cysts, in crude
tubercle, in epithelial tumours, and in pus. The proportion in which it
exists in the fluids of the body is very small. I have made a number of
quantitative analyses of the blood, the results of which I give in the fol-
lowing table, with some of the analyses which have been made for this
substance. I also give the quantity which I have found in the other situa-
tions in which it is found. The variations in different parts of the circulation
and in diseased conditions will be given in another table. The quantity in
the brain and crystalline lens has, I beMeve, never before been estimated : —

Table of Quantity of Cholesterine in various Situations.

Quantity

Cholesterine

Situation.

Observer.

examined.

per 1,000 pts.

Venous blood (male)

Becquerel and Rodier.

0.090

Do. (female)

Becquerel and Rodier.

grains.

0.090

Do. (male set. 35)

A. Flint, Jr.

312.083

0.445

Do. (male set. 22)

A. Flint, Jr.

187.843

0.658

Do. (male set. 24)

A. Flint, Jr.

102.680

0.751

Bile (human)

Frerichs.

1.600

Do. (normal of ox)

Berzelius.

1.000

Do. (human)

A. Flint, Jr.

224.588

0.618

Meconium.

Simon.

160.000

Do.

A. Flint, Jr.

170.541

6.245

Brain (human)

A. Flint, Jr.

159.753

7.729

Do. do.

A. Flint, Jr.

150.881

11.456

Crystalline lens (ox)i

A. Flint, Jr.

135.020

0.907

Fo7'm under ivhicJi the cholesterine exists in the organism. — In the
fluids of the body cholesterine exists in a state of solution, but by virtue
of what constituents it is held in solution, is not entirely settled. It is
stated that the biliary salts have the power of holding it in solution in the
bile, and that the small amount of fatty acids which are contained in the
blood hold it in solution in that fluid, but direct experiments on this point
are wanting. In the nervous substance and in the crystalline lens it is
united ^'molecule d molecuW^ to the other elements which go to make up
these tissues. After it is discharged into the intestinal canal, when it is not \
changed into stercorine, it is to be found in a crystalline form, as in the
meconium, and in the feces of animals in a state of hibernation. In patho-
logical fluids and in tumours, it is found in a crystalline form, and may be
detected by microscopic examination.

Process for the extraction of cholesterine. — Without describing the
processes which have been employed by other observers for the extraction
of cholesterine from the blood, bile, and various tissues of the body, I will
confine myself to a description of the process which I have found most

' In this examination four fresh crystalline lenses of the ox were used.

314 Flint, Jr., New Excretory Function of the Liver. [Oct.

convenient to employ in the analyses I have made for this substance. In
analyses of gall-stones the process is very simple ; all that is necessary
being to pulverize the mass, and extract it with boiling alcohol ; filter the
solution while hot, the cholesterine being deposited on cooling. If the
crystals be coloured, they may be redissolved, and filtered through animal
charcoal. This is the proceeding employed by Poulletier de la Salle,
Fourcroy, and Chevreul. It is only when this substance is mixed with
fatty matters, that its isolation is a matter of any difficulty. In extract-
ing cholesterine from the blood, I have operated on both the serum and clot,
and in this way have been able to demonstrate it in greater quantities in
this fluid than has been observed by others, who have employed only the
serum. The following is the process for quantitative analysis, which I de-
termined upon after a number of experiments.

The blood, bile, or brain, as the case may be, is first carefully weighed,
then evaporated to dryness over a water-bath, and carefully pulverized in
an agate mortar, so as to collect every particle. The powder is then
treated with ether, in the proportion of about a fluidounce for every hun-
dred grains of the original weight, for from twelve to twenty-four hours,
agitating the mixture occasionally. The ether is then separated by filtra-
tion, throwing a little fresh ether on the filter so as to wash through every
trace of the fat, and the solution set aside to evaporate.^ If the fluid,
especially the blood, have been carefully dried and pulverized, when the
ether is added it divides it into a very fine powder, and penetrates every
part. After the ether has evaporated, the residue is extracted with boil-
ing alcohol in the proportion of about a fluidrachm for every hundred
grains of the original weight of the specimen, filtered, while hot, into a
watch-glass, and allowed to evaporate spontaneously. To keep the fluid
hot while filtering, the whole apparatus may be placed in the chamber of a
large water -bath, or, as the filtration is generally rapid, the funnel may be
warmed by plunging it into hot water, or steaming it, taking care that it
be carefully wiped. We now have the cholesterine mixed with a certain
quantity of sapouifiable fat. After the fluid has evaporated, we can see
the cholesterine crystallized in the watch-glass, mingled with masses of fat.
This we remove by saponification with an alkali ; and for this purpose, we
add a moderately strong solution of caustic potash, which we allow to
remain in contact with the residue for from one to two hours. If much fat
be present, it is best to subject the mixture to a temperature a little below
the boiling point ; but in analyses of the blood, this is not necessary. The
mixture is then to be largely diluted with distilled water, thrown upon a
small filter, and thoroughly washed till the solution which passes through
is neutral. We then dry the filter, and fill it up with ether, which, in pass-

1 The ether may be preserved by distillation, instead of allowing it to evapo-
rate, but with the small quantity usually employed this is hardly worth while.

1862.] Flint, Jr., New Excretory Function of the Liver. 315

ing through, dissolves out the cholesterine. The ether is then evaporated,
the residue extracted with boiling alcohol, as before, the alcohol collected
on a watch-glass, previously weighed, and allowed to evaporate. The
residue consists of pure cholesterine, the quantity of which may be estimated
by. weight.

The accuracy of this process may be tested by means of the microscope.
As the crystals have so distinctive a form under the microscope, it is easy
to determine by examining the watch-glass, whether it has been obtained
in a state of purity. In making this analysis quantitatively, it is necessary
to be very careful in all the manipulations ; and for determining the weight
of such minute quantities, an accurate and delicate balance, one, at least, that
will turn with the thousandth of a gramme, carefully adjusted, must be em-
ployed. With these precautions, the quantity of cholesterine in any fluid or
solid may be determined with perfect accuracy. The quantity of cholesterine
may be estimated in from fifteen to twenty grains of blood. In analyzing
the brain and bile, I found it necessary to pass the first ethereal solution
through animal charcoal, to get rid of the colouring matter. In doing this,
the charcoal must be washed with fresh ether till the solution which passes
through is brought up to the original quantity. The other manipulations
are the same as in examinations of the blood. In examining the meco-
nium, I found that the cholesterine which crystallized from the first alco-
holic extract was so pure that it was not necessary to subject it to the action
of an alkali.

I am aware that in describing the process for the extraction of choles-
terine I have entered into details which would be superfluous for the prac-
tical chemist. But the extraction of this substance from the blood .is so
simple, and the results of the examination of blood in different parts of the
circulatory system have been so striking and important, that I cannot but
indulge the hope that the observations which follow will be verified by those
who may not be skilful practical chemists. Almost any one is competent
to make a quantitative analysis of the blood for cholesterine. It simply
requires six days for the process, and a number of analyses may be carried
on at the same time. It requires one day, after the blood has been dried
and pulverized, for the ether to act upon it ; the next morning it is filtered
and set aside ; the next morning it will be dry, and may be extracted with
alcohol, and set aside to evaporate ; the next morning it may be treated
with potash, filtered, and the filter washed with water ; the following day
it may be washed with ether, and set aside to evaporate ; the following day
it will have evaporated, and may be extracted with hot alcohol ; and the
following day the alcohol will have evaporated, and the specimen may be
examined by the microscope and weighed. All that is required is a little
care in the performance of these simple manipulations — which one with a
slight acquaintance with operations in chemistry may perform at once, and

316

Flint, Jr., New Excretory Function of the Liver.

[Oct.

one or two trials will enable a novice to execute — and accuracy in weighing,
which is, indeed, the most delicate part of the process.

History of cholesterine. — A brief sketch of the history of this substance
may not be uninteresting. It was first obtained by Poulletier de la Salle,
in 1782, who extracted it from a biliary calculus. He communicated his
observations to Fourcroy, who published them, after having verified his
experiments, the death of the discoverer preventing him from making his
observations public. Afterwards, in examining an old, hardened, liver,
Fourcroy found a concrete, oily substance, analogous to that discovered by
Poulletier. He imagined that the liver had become changed into a sub-
stance resembling spermaceti. The cholesterine was afterwards found in
gall-stones, by Yicq d'Azyr, by Jaquin, Titius and Kreysig. In 1791
Fourcroy described a substance which he called adipocire, found in bodies
at the cimetiere des Innocents, which he likened to spermaceti and to cho-
lesterine. He always, however, made a distinction between these sub-
stances; calling the cholesterine crystallizahle adipocire. In 1814 Chev-
reul established the difference between the adipocire and the cholesterine,
giving a full description of the cholesterine. He extracted it from the bile
of the human subject, of the bear, and of the pig.

After that time a number of chemists found it in the gall-stones and
intestinal concretions. Lassaigne found it in a cerebral tumour, Guerard
in hydatid cysts of the liver, Morin in the liquid from an abdominal
tumour, Caventou in the matter from an abscess under the malar bone,
and a number of others in tumours in various situations. In 1830 it was
discovered in the blood by Denis, and afterwards described by Boudet, who
wrote an elaborate article on the composition of the serum of the blood in
1833, in which he describes the cholesterine and a new substance which he
called seroline^ It was also detected in normal blood by Lecanu and
Marchand. Couerbe, who made elaborate researches into the chemical
composition of the cerebral substance, pointed out the existence of choles-
terine in the brain. Lebert found it in the substance of cancerous tumours,
Curling found it in the fluid of hydrocele, Simon extracted it from the
meconium, and Preuss discovered it in the substance of crude tubercle. Of
late authors, Becquerel and Rodier have been most extended in their inves-
tigation of this principle.^ They have made a number of careful quanti-
tative analyses of the blood for this substance in health and disease. Their
observations will be more particularly referred to further on.^

' Boudet, Nouvelles Recherclies sur la composition du serum du sang humain.
Annales de Chimie et de Physique, tom. lii. p. 337.

2 Traite de Chimie Pathol ogique appliquee a la medeciii pratique, par M. Alf.
Becquerel, Professeur agrege, etc., et par M. A. Rodier, Docteur en Medecine, etc.
Paris, 11854, and Recherches sur la composition du sang. Paris, 1844.

3 The history of the cholesterine was mostly compiled from the excellent work
of Robin and Verdeil, the Chimie Anatomique,

1862.] Flint, Jr., "New Excretory Function of the Liver. 317

Functions of the cholesterine. — By experiments which I have performed
upon the lower animals, and by certain facts which have been developed by
observations on the human blood in health and disease, I conceive that I
have been enabled to solve the problem of the function of cholesterine.

Cholesterine is an excrementitious product, formed in great part by
the destructive assimilation of the brain and nerves, separated from the
blood by the liver, poured into the upper part of the small intestine with
the bile, transformed in its passage down the alimentary canal into ster-
corine (the seroline of Boudet, a substance differing very little from cho-
lesterine), and, as stercorine, discharged by the rectum.

The quotation with which I prefaced this paper expresses the actual state
of the science with regard to cholesterine. Still, though our actual know-
ledge of its function has been so slight, a few writers on chemical phy-
siology and on physiology, taking the limited data on this subject, make
reference to it as an effete substance. With regard to its relation to the
brain, some think that it is formed in the brain and taken up by the blood,
while others think that it is formed in the blood and deposited in the brain.
All the views with regard to its effete properties are, of course, based on
the supposition that it is discharged in the feces. Effete matters are dis-
charged from the body, and this would find its exit by the anus, since it
has never been detected in the urine. These conjectures have attracted
little attention in the scientific world ; and these views being based on the
supposition that this substance is formed in the fecal matters, fall to the
gi'ound from the fact that no one as yet detected it in the feces. The fact
that cholesterine is so generally considered"an ingredient of the feces may
be thus explained. It is poured into the alimentary canal with the bile ;
no one has shown what becomes of it, the chemistry of the feces being little
understood, and therefore it has been assumed that it is found in the feces.
That the facts which we have with regard to cholesterine render its eliete
properties possible, and, perhaps, probable, is certainly true; but these
facts are merely sufficient to enable the scientific investigator to address an
intelligent inquiry to nature on this subject ; they do not resolve the ques-
tian, . In the experiments which form the basis of this article, the inquiry
was made and the answer obtained ; some others have, without much
reflection, apparently, made simple statements which approximate in some
degree to the facts. The only way these assertions could be sustained is
by the labour which I have expended in eliciting from nature a reply to
my interrogatories.

The works which I have had an opportunity of consulting where any
decided opinion relative to the function of cholesterine has been expressed,
are those of Carpenter, Lehmann, Mialhe, and Dalton.^

^ These authors are quoted in the order in which their publications appeared.

318

Flint, Jr., New Excretory Function of the Liver.

[Oct.

Carpenter, in the fifth American edition of his Human Physiology,
1853, has the following with regard to the function of cholesterine.

" It is also stated to be a constituent of the nervons tissue, having been ex-
tracted from the brain by Couerbe, and other experimenters ; but it may be
doubted whether this is not rather a product of the disintegration of nerve-sub-
stance, which is destined to be taken back into the blood for elimination by the
excretory apparatus, like the kreatine which may be extracted from the juice of
flesh, or the urea which is obtainable from the vitreous humour of the eye, both
being undoubtedly excrementitious matters. For cholesterine is a characteristic
component of the biliary excretion, and is closely related to its peculiar acids ;
so that it can scarcely be looked upon in any other light than as an excremen-
titious product, the highest function of which is to assist in the support of the
calorifying process. It is frequently separated from the blood as a morbid pro-
duct ; thus it is often present in considerable quantity in dropsical fluids, and
particularly in the contents of cysts ; and it may be deposited in the solid form
in degenerated structures, tubercular concretions, &c."^

In Lehmann, we find the following on this subject : —

"Judging from the mode of its occurrence, we must regard it aS a product of
decomposition ; but from what substances and by what processes it is formed,
it is impossible even to guess. Notwithstanding the similarity which many of
its physical properties present to those of the fats, we can hardly suppose that
it takes its origin from them, since the fats, for the most part, become oxidized
in the animal body, whereas in order to form cholesterine, they must undergo a
process of deoxidation."^

I translate the following from the excellent work of Mialhe, on Chemis-
try applied to Physiology and Therapeutics, Paris, 1856, the paragraph
entitled " Source of Cholesterine in the Animal Economy."

"We have just examined in what manner the fatty bodies penetrate into the
blood. Some eminent savans have held that the fatty matters from the exterior
are the only ones which exist in the economy, and that it is incapable of pro-
ducing these in itself Now it is an opposite opinion which tends to predomi-
nate, and the majority of physiologists think that certain fatty bodies take origin
in the very substance of our organism. This last mode of origin seems at least
incontestable for the cholesterine, which has not yet been found in the vegetable
kingdom.

"But what are the chemico-physiological reactions which preside over the
development of this particular fatty substance ?

" There are for us two modes for comprehending the formation of the choles-
terine at the expense of the elements of the blood. Cholesterine may come from
the fatty matters ; it would be, in this case, like the final result or last stage of
chemical modifications which the fatty matters undergo in the animal economy.

" This manner of viewing it is slightly probable ; for. in order that it should
be true, it would be necessary that the fatty bodies, in oxidizing, should give rise
to a compound richer than they in carbon. "We know, indeed, that cholesterine
is, of all fatty bodies, the one which contains the most carbon.

"We think that we should reject that opinion and stop at the following.

" The production of cholesterine may be attributed to a transformation of the
albuminoid materials, a transformation analogous to that which has been pointed
out by M. Blondeau de Carrolles in cheese, and which that chemist has desig-
nated under the name of adipose fermentation. The large proportion of carbon
which the cholesterine contains, and which approxinjates it to albuminous mat-
ters, would come to the support of that point of view. The retardation of the

' Carpenter's Principles of Human Physiologj, page 74. Pliiladelpliia, 1853.
2 Physiological Chemistry, by Professor C. Gr. Lehmann, vol. i. 24S. Philadel-
phia, 1855.

1862.] Flint, Jr., I^ew Excretory Function of the Liver. 819

circulation, and the deficiency of oxidation which is the consequence of it,
explains also why the cholesterine is in much greater proportion in the closed
cavities than in the blood itself.

" Whichever it may be of these two opinions, it is incontestable for us that, if
the cholesterine be not burned with the other matters proper to respiratory
alimentation, it is solely on account of its chemical inertia ; cholesterine, indeed,
is to fatty matters what mannite is to saccharine substances — what urea is to
albuminoid matters ; that is to say, that it constitutes a kind of caput mortuum,
of which the organism has only to free itself It is certain also, for us, that if
the cholesterine is not found in all the excrementitious liquids, where most of the
other products existing in the blood are found, it is solely on account of its
insolubility.

" The preceding remarks explain perfectly, to our eyes at least, why the pre-
sence of cholesterine has never been established in the urine of man, either in
the form of crystals, or ' calculi,' while this substance is found in the bile, where
it very often forms calculi of considerable size. Cholesterine, indeed, is insoluble
in acid liquids, such as the urine ; while it is soluble in soapy liquids, such as
the bile. Such is solely the reason why the cholesterine is excreted by the biliary
passages."'

Finally, in Dalton's Treatise on Human Physiology, we find the fol-
lowing paragraph in which the subject of cholesterine is considered : —

" Cholesterine (C25H22O). — This is a crystallizable substance which resem-
bles the fats in many respects, since it is destitute of nitrogen, readily inflam-
mable, soluble in alcohol and ether, and entirely insoluble in water. It is not
saponifiable, however, by contact with the alkalies, and is distinguished on this
account from the ordinary fatty substances. It occurs, in a crystalline form,
mixed with colouring matter, as an abundant ingredient in most biliary calculi,
and is found also in different regions of the body, forming a part of various
morbid deposits. We have met with it in the fluid of hydrocele, and in the in-
terior of many encysted tumours. The crystals of cholesterine have the form of
very thin, colourless, transparent, rhomboidal plates, portions of which are ofton
cut out by lines of cleavage parallel to the sides of the crystal. They frequently
occur deposited in layers, in which the outlines of the subjacent crystals show
very distinctly through the substance of those which are placed above. Choles-
terine is not formed in the liver, but originates in the substance of the brain
and nervous tissue, from which it may be extracted in large quantity by the
action of alcohol. From these tissues it is absorbed by the blood, then conveyed
to the liver, and discharged with the bile."^

The above extracts embrace all that I have been able to find bearing on
the question of the function of cholesterine. The extracts from Mialhe and
Dalton contain all that is said by them on this subject. Those from Carpen-
ter and Lehmann contain only what bears on the function of this substance,
the .chemical details being omitted. Of the authors cited, Mialhe is the
most extended on the subject, and is almost the only one who adduces any
arguments to support his views ; but his opinions are biased by the purely
chemical view which he takes of the subject, and are involved with the
ideas w^ith reference to plastic and calorific food, now rejected by many

1 CMmie appliquee a la Phjsiologie et a la Tlierapeutique. Par M. le Docteur
Mialhe. Page 191. Paris, 1856.

2 A Treatise on Human Physiologj, designed for the use of Students and Prac-
titioners of Medicine. By John C. Dalton, Jr., M. D., Professor of Phvsiologj and
Microscopic Anatomy in tlie College of Physicians and Surgeons, New Yoi'k, &c.
Page 189. Pliiladelpbia, 1861.

320 Flint, Jr., New Excretory Function of the Liver. [Oct.

eminent physiologists, and which, I conceive, will be so little supported by
future advances in science, that they will soon be universally discarded, in
the exclusive sense in which they are received by him. Putting these
hypotheses aside, we examine the actual state of our science, with regard
to cholesterine, and we find that the functron, up to this time, has not been
established. We will now proceed to the facts which tend to support the
statement I have made on this point.

Cholesterine exists in the blood, from which it maybe extracted in a state
of purity, and estimated by the process which I have already indicated.
Becquerel and Rodier have made analyses of the healthy human blood for
this substance with the following results: —

Venous "blood of tlie male .... 0.09 pts. per 1.000
" " " female . . . 0.09 " " "

I have made a quantitative analysis of three specimens of healthy human
blood with the following results : —

Quantity of Blood. Cholesterine. Proportion

grains. grains. per 1,000 pts.

Venous blood from the arm ; male set. 35 312.083 0.139 0.445

Do. do. do. (coloured) set. 22 187.843 0.123 0.658

Do. do. do. get. 24 102.680 0.077 0.751

These three analyses were all carried on at the same time, and each spe-
cimen subjected to precisely the same process. The results show a wide
range within the limits of health. The difference was not due to any vari-
ation relating to the digestive process, as the specimens were all drawn at
the same time, and were taken from prisoners on Blackwell's Island, who
were subjected to the same diet, and ate at the same time. It will be seen
by this table that I have obtained from five to eight times as much as is
indicated by Becquerel and Bodier. I can only explain this by the fact
that I operated on the whole blood, while they only analyzed the serum.
Boudet states that it is necessary to make three to four copious bleedings,
and mix the serum in order to obtain a sufficient quantity for a satisfactory
analysis. I have operated on about fifty grains of blood with success, and
have no doubt but that I would be able to extract the cholesterine in a
crystalline form, and estimate its quantity in fifteen and twenty grains.
The purity of the extract can easily be demonstrated by a microscopic
examination. I conclude, then, that a much larger quantity of cholesterine
exists normally in the blood than has been supposed, and that its variations,
in different persons, within the limits of health, are considerable.

The next question which naturally arises is the origin of the cholesterine.
When we examine the situations in which it is found, we find that it exists
in largest quantity in the substance of the brain and nerves. It is also
found in the substance of the liver, probably in the bile which is contained
in this organ, and the crystalline lens, but with these exceptions it is found

1862.] Flint, Jr., New Excretory Function of tlie Liver. 321

only in the nervous system and blood. Two views present themselves with
regard to its origin. Cholesterine is deposited in the nervous matter from
the blood, or is formed in the brain and taken up by the blood. This is a
question, however, which can be settled experimentally, by analyzing the
blood for cholesterine as it goes to the brain by the carotid, and as it
comes from the brain by the internal jugular. The cholesterine being
found also in the nerves, and, of course, a large quantity of nervous matter
existing in the extremities, it is desirable at the same time to make an
analysis of the venous blood from the general system.

With reference to this question the following experiment was made : —

Exp. 3. A medium sized dog, about six months old, fasting,. was put
under the influence of ether. The carotid and internal jugular were ex-
posed on the left side, and the animal allowed to come out from the effects
of the anaesthetic. Two hours after, he was again etherized, and the blood
taken from the following vessels in the order in which they are named : 1,
Internal jugular ; 2, Carotid; 3, Yena cava; 4, Hepatic veins; 5, Hepatic
artery ; 6, Portal vein. In the operation of drawing the blood from the
abdominal vessels, immediately after opening the abdomen a ligature was
applied to the vena cava and a little blood taken, which prevented the
blood from the inferior extremities from mixing with the hepatic blood.
The blood was then taken from the hepatic veins, a matter of some diffi-
culty, as it is always more or less mingled with blood returning through the
thoracic vena cava, and a ligature applied to the hepatic artery and portal
vein. The blood was then drawn from the hepatic artery and portal vein.^
A quantity of bile was then taken from the gall-bladder, and a portion
taken from the substance of the brain. These specimens were received into
carefully weighed vessels and weighed ; but as I failed to make a quantita-
tive analysis, my process of extraction not having been perfected, it is
unnecessary to enter into their details. They were then dried and pul-
verized, treated with ether, evaporated, the residue extracted with hot
alcohol, allowed to evaporate spontaneously, and examined with magnify-
ing powers of tO, 270, and 400 diameters successively. The residue of
the bile and brain were found to consist of nearly pure cholesterine, but
in all the other specimens, excepting that from the internal jugular, the
appearance of cholesterine w^as doubtful. They all contained, with masses

' The operation of collecting the blood from any particular vessel is by no means
so easy as might at first be supposed. The greatest care is necessary in order to
obtain it unmixed. This is particularly so in the case of the hepatic vein, the
unmixed blood from which it is exceedingly difiicult to obtain. In drawing blood,,
the operation must be done as rapidly as possible to avoid the derangements of the
circulation which arise from exposure of the vessels, pressure, etc. In taking
blood going to and coming from a part, it must always be taken from the vein first ;
as ligating or compressing the artery would of course arrest the circulation. As
the blood in the arterial system is not subject to the same changes in composition
as the blood in the difi"erent veins, any specimen of the arterial blood will repre-
sent the blood going to a part, unless, like the liver, it receives blood from the
venous system. The collection of blood I have found the most difficult part of these
investigations.

No. LXXXYIIL— Oct. 1862. 21

322 Flint, Jr., New Excretory Function of the Liver. [Oct.

of ordinary fat, crystals of stercorine.* There were a few distinct plates of
cholesterine in the specimen from the internal jugular. The specimens
w^ere then treated with a solution of caustic potash and set aside. In two
days part of the potash was removed with bibulous paper and portions of
the precipitates taken out, placed upon slides, and examined microscopi-
cally with Jth and y^gth inch objectives successively. The watch-glasses
were then set aside, carefully protected from the dust, and examined again
ten days after, when they had become entirely dry. The following was the
result of the examinations of the extracts of blood from the carotid, in-
ternal jugular, vena cava, and the extract of the brain. The examination
of the other specimens has nothing to do with the question now under
consideration, and their description is deferred.

Blood from the carotid artery. — First examination, three days after
the operation, discovered a large number of small crystals of stercorine
and masses of fat ; but after the most careful examination, prolonged for
t-wo hours, I failed to discover any crystals of cholesterine. The appear-
ance is represented in Fig. 2.

The second examination, eleven days after, discovered a small quantity of
cholesterine mixed with the matters noted in the first examination. This
appearance is represented in Fig. 3.

Substance of the brain. — All the microscopic examinations of the ex-
tract from the brain showed crystals of cholesterine in large quantity.
The crystals from the brain are described by Robin as being thinner and
more elongated than those found in other situations.^ This peculiarity I
also noticed. The appearance is represented in Fig. 4.

Blood from the internal jugular. — In the first examination of the
specimen from the internal jugular, after the blood had been treated with
ether, the ether allowed to evaporate, and the residue extracted with hot
alcohol, well-marked plates of cholesterine were noted. At this time it
could not be discovered in any of the other specimens of blood after the
most careful and patient examination. After the caustic potash had been
added, the cholesterine was demonstrated in large quantity, with a few
crystals of stercorine. The appearance is represented in Fig. 6, which was
drawn eleven days after the blood was collected. Another examination
was made on the following day, which showed, in addition to the choleste-
rine, a considerable quantity of stercorine. (See Fig. 6.)

Blood from the vena cava. — The extract of the blood from the vena
cava, examined eleven days after the blood was drawn, showed a large
quantity of stercorine and a few crystals of cholesterine. The cholesterine
was distinct but not very abundant. (See Fig. 7.)

These experiments, the first that I made on this subject, demonstrate
the following facts : 1. That the brain contains a large quantity of choles-

' Stercorine, or seroline, is a non-saponifiable fatty substance resembling the
cholesterine in many of its chemical pxoperties, but fusing at a much lower tem-
perature. It was discovered in the serum of the blood by Boudet about 1833. It
crystallizes in the form of needles, which will be more particularly described when
we treat of the extraction of this substance from the feces. As I have found it in
great abundance in the feces, and am disposed to doubt its existence as a natural
consti-tuent of the serum of the blood, I have called it stercorine, for reasons which
•will be more fully exposed further on.

2 Traite de Chimie Anatomique, Robin and "V^erdeil, tome iii. p. 57.

1862.] Flint, Jr., New Excretory Function of the Liver.

323

terine (which had, however, been previously established). 2. That the blood
going to the brain contains a small quantity of cholesterine, while the
blood coming from the brain contains a large quantity. 3. That the blood
coming from the lower extremities and pelvic organs contains more choles-
terine than the blood carried to them by the arterial system.

It was only necessary to confirm these statements by further investiga-
tion, to be enabled to deduce from them the following important conclu-
sion : i. e. That cholesterine is formed in some of the tissues of the body ; and,
judging from the fact that the nervous tissue is the only one in which it is
found, and that the blood gains it in its passage through the great nervous
centre, it is formed, in great part, by the nervous system. After the first
experiment, which almost confirmed the supposition with which I had
started, I directed my attention to the perfection of a process by which I
might make an accurate quantitative analysis of the blood for cholesterine,
so as to be able to state positively that it gained cholesterine in its pas-
sage through certain organs, and furthermore to determine the amount of
increase. After a number of experiments, I fixed upon the process which
I have minutely described in the first part of this article, and made the
following experiments for the purpose of ascertaining the quantity of
cholesterine produced in the brain.

Exj). 4. A medium sized adult dog was put under the influence of ether
and the carotid artery, internal jugular, and femoral veins exposed. Spe-
cimens of blood were drawn, first from the internal jugular, next from the
carotid, and last, from the femoral vein. These specimens were received
into carefully weighed vessels, and weighed.

Tiiey were then analyzed for cholesterine by the process described on
pages 313-315, and the following results obtained : —

Quantity of Blood. Cholesterine. Cholesterine per
grains. grains. 1,000 pts.

Carotid .... 179.462 0.139 0.774

Internal jugular . . 134.780 0.108 0.801

Femoral vein . . . 133.886 0.108 0.806

Percentage of increase in blood from the jugular over the arterial blood 3.488
Do. do. of blood from femoral vein .... 4.134

This experiment shows an increase in the quantity of cholesterine in the
blood, during its passage through the brain and an increase, even a little
greater, in the blood passing through the vessels of the posterior extremity.
To facilitate the operation, however, the animal was brought completely
under the influence of ether, \which, from its action on the brain, would not
improbably produce some temporary disturbance in the nutrition of that
organ, and consequently interfere with the experiment. For the purpose
of avoiding this difficulty I performed the following experiments without
administering an anaesthetic.

Exp. 5. A small young dog was secured to the operating table, and the
internal jugular and carotid exposed on the right side. Blood was taken,
first from the jugular, and afterwards from the carotid. The femoral vein

324

Flint, Jr., Xew Excretory Function of the Liver. [Oct.

on the same side was then exposed and a specimen of blood taken from
that vesseL The animal was very quiet under the operation, though no
antesthetic was used, so that the blood was drawn without any difficulty
and without the slightest admixture.

The three specimens were analyzed for cholesterine with the following
results : —

Quantity of Blood. Cholesterine. Cholesterine per
'grains. grains. 1,000 pts.

Carotid .... 143.625 0.679 0.967

Internal jugular . . 29.956 0.046 1.545

Femoral vein . . . 45.035 0.046 1.028

Percentage of increase in blood from the jugular over arterial blood 59.772
Do. do. of blood from the femoral vein . . . 6.308

Exp. 6. A large and powerful dog was secured to the operating table
and the carotid and internal jugular exposed. Specimens of blood were
taken from these vessels, first from the jugular, carefully weighed and
analyzed for cholesterine in the usual way. The following results were
obtained : —

Blood. Cholesterine. Proportion in

grains. grains. 1,000 pts.

Carotid .... 140.847 0.108 0.768

Internal jugular . . 97.811 0.092 0.947

Percentage of increase in passing through the brain . . . 23.307

Exp. 5 shows a very considerable increase in the quantity of cholesterine
in the blood passing through the brain, while it is comparatively slight in
the blood of the femoral vein. The proportion of cholesterine is also large
in the arterial blood compared with other observations.

Exp. 6 shows but a slight difference in the quantity of cholesterine in
the arterial blood in the two animals; the proportion in the animal that
was etherized being 0.774 pts. per 1,000, and in the animal that was not
etherized 0.768 per 1,000, the difference being but 0.006; but, as I had
suspected, the ether had an influence on the quantity of cholesterine absorbed
by the blood in its passage through the brain. In the first instance the
increase was but 3.488 per cent, while in the latter it was 23.307. Unfor-
tunately the blood was not taken from the femoral vein. I intended to
take blood from the abdominal organs, but after opening the abdomen the
struggles of the animal were so violent that this was impossible, and he
was killed.

What are our natural conclusions, from the preceding experiments, with
regard to the origin of cholesterine in the economy ? It has been found
that the brain and nerves contain a large quapntity of this substance, which
is found in none other of the tissues of the .body. The preceding experi-
ments, especially Exps. 5 and 6, show that the blood which comes from the
brain contains a much larger quantity of cholesterine than the blood which
goes to this organ.

The conclusion is, then, that it is produced in the hroAn, and thence
absorbed by the blood.

But the brain is not the only part where cholesterine is produced. It

1862.] Flint, Jr., New Excretory Functiou of the Liver.

325

will be seen by Exp. 4 that there is 4.134 per cent., and in Exp. 5, 6.308
per cent, of increase in the cholesterine in the passage of the blood through
the inferior extremities, and probably about the same in other parts of the
muscular system. In examining these tissues chemically, we find that the
muscles contain no cholesterine, but that it is abundant in the nerves ; and
as we have found that the proportion of cholesterine is immensely increased
in the passage of the blood through the great centre of the nervous system,
taken, as the specimens examined were, from the internal jugular, which
collects the blood from the brain and very little from the muscular system,
it is rendered almost certain, that in the general venous system, the choles-
terine which the blood contains is produced in the substance of the nerves.

If this be true, and if, as I hope to show, the cholesterine be a product
of the destructive assimilation of nervous tissue, its production would be
proportionate to the activity of the nutrition of the nerves; and anything
which interfered to any great extent with their nutrition would diminish
the quantity of cholesterine produced. In the production of urea by the
general system, which is an analogous process, muscular activity increases
the quantity, and inaction diminishes it, on account of the effect upon
nutrition. In cases of paralysis we have a diminution of the nutritive
forces in the parts affected, especially of the nervous system, which, after a
time, becomes so disorganized, that although the cause of the paralysis be
removed, the nerves cannot resume their functions. It is true we have this
to a certain extent in the muscles; but it is by no means as marked as it
is in the nerves. We should be able then to confirm the observations on
animals, by examining the blood in cases, of paralysis ; when we should find
a very marked difference in the quantity of cholesterine, between the venous
blood coming from the paralyzed parts, and that from other parts of the
body. With this in view I made analyses of the blood from both arms in
three cases of hemiplegia, which seemed to me most suitable for such a
comparison.

Case I. Sarah Rumsby, ^t. 4t, affected with hemiplegia of the left side.
Two years ago she was taken with apoplexy, and was insensible for three
days. When she recovered consciousness she found herself paralyzed on
the left side. Said she had epilepsy four or five years before the attack of
apoplexy. Now she has entire paralysis of motion on the affected side,
with the exception of some slight power over the fingers, but sensation is
perfect. The speech is not affected. The general health is good.

Case II. Anna Wilson, ast. 23, Irish, affected with hemiplegia of the right
side. Four months ago she was taken with apoplexy, from which she
recovered in one day with loss of motion and sensation on the right side.
She is now improving and can use the right arm slightly. The leg is not
so much improved, because she will make no effort to use it.

Case III. Honora Sullivan, Irish, a3t. 40, affected with hemiplegia of
right side. About six months ago she was taken with apoplexy, and
recovered consciousness the next day, with paralysis. The leg was less
affected than the arm, from the first. The cause was supposed by Dr. Flint,

326 Flint, Jr., New Excretory Function of the Liver. [Oct.

the attending physician, to be due to an embolus. Her condition is now
about the same as regards the arm, but the leg has somewhat improved.

These cases all occurred at the Blackwell's Island Hospital. The treat-
ment in all consisted of good diet, frictions, passive motion, and use of the
paralyzed members as much as possible.

A small quantity of blood was drawn from both arms in these three
eases. It was drawn from the paralyzed side, in each instance, with great
difficulty, and but a small quantity could be obtained.

The specimens were all examined for cholesterine with the following
results : —

Table of Quantity of Cholesterine in Blood of Paralyzed and Sound Sides
in three cases of JSemi2:)legia.

Blood.

Clioles-
teriae.

Cliolesteriiie per 1,000. ,

Case I. Paralyzed side.
Do. Sound side.

grains.
55.458

128.407

grains.
0.062

The watch-glass contained 0.031 grain
of a substance, but the most careful
examination failed to show a single
crystal of cholesterine.
0.481.

Case II. Paralyzed side.
Do. Sound side.

18.381
66.396

0.062

Same as Case I.
0.808.

Case III. Paralyzed side.
Do. Sound side.

21.842
52.261

0.031

Same as Case I.
0.579.

The result of these examinations is very interesting: not a single crystal
of cholesterine was found in any of the three specimens of blood from the
paralyzed side, while about the normal quantity was found in the blood
from the sound side. As the nutrition of other tissues is interfered with
in paralysis, it is impossible to say positively from these observations alone,
that the cholesterine is produced in the nervous system only. But the
nutrition of the nerves is undoubtedly most affected ; and this observation,
taken in connection with the preceding experiments on animals, seem to
settle where the cholesterine is produced.

We may extend our first conclusion, then, and state that the cholesterine
is produced in the substance of the nervous system.

Before entering upon the character of cholesterine, and inquiring whether
it be an excrementitious or a recrementitious product, we will endeavour to
follow it out in the system and ascertain if there be any organ which sepa-
rates it from the blood. In pursuing this question, the method will be
adopted that has been employed in investigating its origin; that is, ana-
lyzing the blood as it goes to and comes from certain organs. The organ
which we would be led first to examine is the liver, as it is the only gland,
the product of which contains cholesterine, which, if not manufactured in
the gland itself, must be separated from the blood.

1862.] Flint, Jr., 'New Excretory Function of the Liver.

32Y

In the first series of experiments which I performed on this subject, I en-
deavoured to show on the same animal the origin of cholesterine in certain
parts, and its removal from the body. In these experiments, which were only
approximative, as I had not then succeeded in extracting the cholesterine
perfectly pure, I commenced with the arterial blood, examining it as it went
into the brain by the carotid, analyzing the substance of the brain, then
analyzing the blood as it came out of the brain by the internal jugular,
examining the blood as it went into the liver by the hepatic artery and
portal vein, examining the secretion of the liver, then the blood as it came
out of the liver by the hepatic vein, examining also the blood of the vena
cava in the abdomen. The analyses of the blood from the carotid, internal
jugular, and vena cava have already been referred to, pages 323, 324, in treat-
ing of the origin of the cholesterine. It will be remembered that there was
a large quantity of this substance in the internal jugular, and but a small
quantity in the carotid, showing that it was formed in the brain. I now
give the conclusion of those observations, which bears upon the separation
of the cholesterine from the blood.

Exp. Y. Specimens of blood were taken from the hepatic artery, portal
vein and hepatic vein, and a small quantity of bile from the gall-bladder.
These specimens were treated in the manner already indicated in Exp. 3;
i. e., evaporated and pulverized, extracted with ether, the ether evaporated,
and the residue extracted with boiling alcohol, this evaporated, a solution
of caustic potash added and then subjected to a microscopic examination.

Blood from the portal vein. — Microscopic examination of the extract
from the portal vein showed quite a number of crystals of cholesterine,
which are represented in Fig. 8. These were observed after the fluid had
nearly evaporated.

Blood from the hepatic artery. — Microscopic examination of the ex-
tract from the hepatic artery, made after the fluid had nearly evaporated,
showed a considerable amount of cholesterine ; more than was observed in
the preceding specimen. (See Fig. 9.) There were also observed a few crys-
tals of stercorine, represented in Fig. 10.

Blood from the hepatic vein. — The first examination of the extract
from the hepatic vein, which was made just before the potash was added,
showed a number of fatty masses with some crystals of stercorine. The
solution of potash was then added, and two days after, another careful exa-
_mination was made, discovering nothing but fatty globules and granules.
(See Fig. 11.) The watch-glass was then set aside, and was examined eleven
days after, when the fluid had entirely evaporated. At this examination, a
few crystals of cholesterine were observed for the first time. (See Fig. 12.)
There were also a number of crystals of margaric and stearic acid.

Bile. — All the examinations of the extract from the bile showed choles-
terine ; the precipitate consisted, indeed, of this substance in a nearly pure
state. Fig. 13 represents some of the crystals which were observed in this
specimen.

This series of experiments being taken in connection with the first obser-
vations on the carotid and internal jugular, while the one series demonstrates
pretty conclusively that cholesterine is formed in the brain, the other shows

B28

Flint, Jr., New Excretory Function of the Liver. [Oct.

that it disappears, in a measure, from the blood in its passage through the
liver, and is found in the bile. In other words, it is formed in the nervous
tissue, and prevented from accumulation in the blood by its excretion by
the liver. This suggests an interesting series of inquiries ; and this fact,
substantiated, would be as important to the pathologist as to the physiolo-
gist. But in order to settle this important question, it is necessary to do
something more than make an approximative estimate of the quantity of
cholesterine removed from the blood by the liver. The quantity which is
thus removed in the passage of the blood through this organ should be
estimated, if possible, as closely as the quantity which the blood gains in
its passage through the brain. But this estimate is more difiScult. The
operation for obtaining the blood, in the first place, is much more serious
than that for obtaining blood from the carotid and internal jugular. It is
very difficult to obtain the unmixed blood from the hepatic vein ; and the
exposure of the liver, if prolonged, must interfere with its eliminative
function, in the same way that exposure of the kidneys arrests, in a few
moments, the flow from the ureter. It is probable, however, that the ad-
ministration of ether does not interfere with the elimination of cholesterine
by the liver as it does, apparently, with its formation in the brain. Anaes-
thetics, we know, have a peculiar and special action on the brain, but do
not interfere with the functions of vegetative life, like secretion or excre-
tion ; and, we would suppose, would not interfere with the depurative
function of the liver. It is fortunate that this is the case, for the opera-
tion of taking blood from the abdominal vessels is immensely increased in
difficulty by the struggles of an animal not under the influence of an anaes-
thetic, so much so, indeed, that I failed entirely in obtaining any blood
from one animal (the one used in Exp. 6), which was not etherized. It
was a very powerful dog, and his struggles were so violent that it was im-
possible to collect the blood accurately from the abdominal vessels, and the
attempt was abandoned. With the view of settling the question of the dis-
appearance of a portion of the cholesterine of the blood in its passage
through the liver, by an accurate quantitative analysis, I repeated the ope-
ration for drawing blood from the vessels which go into, and emerge from
the liver. In my first trial the blood was drawn so unsatisfactorily, and
the operation was so prolonged, that I did not think it worth while to
complete the analysis, and abandoned the experiment. In the following
one I was more successful.

Exp. 8. A good-sized bitch (pregnant) was brought completely under
the influence of ether, the abdomen laid freely open, and blood drawn,
first from the hepatic vein, and next from the portal vein. The taking of
the blood was entirely satisfactory, the operation being done rapidly, and
the blood collected without any admixture. A specimen of blood was then
taken from the carotid to represent the blood from the hepatic artery.

The three specimens of blood were then examined in the usual way for
cholesterine, with the following results : —

1862.] Flint, Jr., New Excretory Function of the Liver. 329

Blood. Cholesterine. Cholesterine in

grains. grains. 1000 pts.

Arterial blood . . . 159.537 0.200 1.257

Portal vein . . . 168.257 0.170 1.009

Hepatic vein . . . 79.848 0.077 0.964

Percentage of loss in arterial blood in its passage through the liver 23.309
Do. do. do. of portal vein .... 4.460

This experiment proves positively that there was good ground for sup-
posing from Exp. T, namely, that cholesterine is separated from the
blood by the liver ; and here we may note, in passing, a striking coincidence
between the analysis in Exp. 6, when the blood was studied in its pas-*
sage through the brain, and the one just mentioned, when the blood was
studied in its passage through the liver. The gain of the arterial blood
in cholesterine in passing through the brain was 2^.301 per cent., and
the loss of this substance in passing through the liver is 23.309 per cent.
There must be, of course, the same quantity separated by the liver that
was formed by the nervous system, it being formed, indeed, only to be sepa-
rated by this organ, its formation being continuous, and its removal neces-
sarily the same, in order to prevent its accumulation in the circulating fluid.
The almost exact coincidence between these two quantities, in specimens
taken from different animals, though not at all necessary to prove the fact
just mentioned, is still very striking.

It is shown by Exp. 8 that the portal blood, as it goes into the liver,
contains but a small percentage of cholesterine over the blood of the
hepatic vein, while the percentage in the arterial blood is large. The arte-
rial blood is the mixed blood of the entire system, and as it probably passes
through no organ before it gets to the liver which diminishes its choleste-
rine, contains a quantity of this substance, which must be removed. The
portal blood, coming from a limited part of the system, contains less of this
substance, though it gives up a certain quantity. In the circulation of the
liver, the portal system largely predominates, and is necessary to other im-
portant functions of this organ, such as the production of sugar and fat.
Soon after the portal vein enters the liver, its blood becomes mixed with
that from the hepatic artery,^ and from this mixture the cholesterine
is separated. It is only necessary that blood, containing a certain quantity
of cholesterine, should come in contact with the bile-secreting cells, in order
that this substance be separated. The fact that it is eliminated by the liver
is proven with much less difficulty than that it is formed in the nervous
system. In fact, its presence in the bile, the necessity of its constant re-

1 According to Robin, the branches of the hepatic artery are distributed almost
entirely in the interlobular plexuses, and on the walls of the hepatic duct and
portal vein, and do not find their way into the substance of the lobules. — Diction-
naire de Medecine, de Chirurgie, de Pharmacie, des Sciences accessoires et de VArt
veterinaire de P. H. Nysten ; onzihme Edition revue et corrige. Par E. Littre et Ch.
Robin. Paris, 1858. Article Foie.

330 Flint, Jr., 'New Excretory Function of the Liver. [Oct.

moval from the blood, which is consequent on its constant formation and
absorption by this fluid, are almost sufficient in themselves to warrant the
conclusion that it is removed by the liver. This, however, is put beyond a
doubt by the preceding analysis of the blood going to and coming from
this organ.

Another link, then, is added to the chain of facts which make up the
history of cholesterine. The first is that —

Cholesferine is formed in the brain and nervous system, and absorbed
*by the blood.

The second, which has just been proven, is that —

Cholesterine, formed in these situations, and absorbed by the blood, is
separated from the blood in its passage through the liver.

The next question, in following out this line of inquiry, is, What becomes
of the cholesterine which is separated from the blood ? This question is
very easily answered, and necessitates only an examination of one of the
products of the liver, the bile.

The Bile. — In the few remarks with which I prefaced this article, I
spoke of the various opinions which are held among physiologists with
reference to the function of the bile — some regarding it as purely excre-
mentitious, others placing it among the recrementitious fluids. I detailed
experiments which led me to think that it had two distinct functions : one,
which is recrementitious, and is probably concerned in digestion to an im-
portant degree, but which it is not designed to take up in this connection ;
the other, which is excrementitious, and which is necessarily taken up in
our discussion of the important principle which we are now considering.
A glance at the composition of the bile will show that it is an exceedingly
complex fluid ; and physiological investigations into the destination of cer-
tain of its ingredients, by Bidder and Schmidt, Dalton and others, have
shown that they are not discharged from the body, but resorbed by the
blood; though the failure to detect them in the portal blood by the appro-
priate tests, shows that in this resorption they probably undergo some
alteration.^ These substances, which have heretofore been considered the
most important ingredients of the bile, though their function is obscure,
are the glyco-cholate and tauro-cholate of soda, discovered by Strecker in
the bile of the ox in 1848. The following is the composition of the bile
given in Dalton's Physiology, which is "based on the calculations of Ber-
zelius, Frerichs, and Lehmann."^

' For a very complete account of the bile, witli origiBal investigations into the
destination of the biliary salts, the reader is referred to an article published by
Prof. John C. Daltou, Jr., in the American Journal of the Medical Sciences, October,
1857, and the chapter on bile in Dalton's Physiology.

2 Dalton's 'Physiology, second edition, page 158.

1862.] Flint, Jr., New Excretory Function of the Liver. 331

Composition of Ox Bile.

Water .........

Glyco-cliolate of soda .......

Tauro-cliolate of soda .......

Biliverdine

Fats . .

Oleates, margarates, and stearates of soda and potassa

Cholesterine s . .

Chloride of sodium .......

Phosphate of soda

Phosphate of lime

Phosphate of magnesia ......

Carbonates of soda and potassa . .

Mucus of the gall-bladder

888.00

90.00

13.42

15.24

1.34

1000.00

Of the above ingredients of the bile, we have the biliverdine, which is
simply a colouring matter, the fats, with the oleates, margarates, and
stearates, which, with the biliary salts, are said to hold the cholesterine in
solution, the chloride of sodium, present in all the animal fluids, the phos-
phates and carbonates, which are simply excreted, and are also ingredients
of the urine, leaving, as the most important constituents, of which the
function is least understood, the biliary salts and the cholesterine. The
biliary salts are probably recrementitious; but the cholesterine is one of the
great products of the waste of the system. The bile, then, presents the
combined character, so far as its chemical composition is concerned, of a
secretion and of an excretion. Let us now contrast these two properties,
and see what this fluid has in common with the secretions, and how it
obeys the laws which regulate the excretions. In doing this we will first
contrast some of the important distinctions between these two classes of
products.

Secretions are characterized by certain elements which are manufactured
in the substance of the gland, and are found in no other situation. Such
is the pancreatine for the pancreatic juice, the pepsin for the gastric juice,
the ptyaline for the saliva, and, we may add, the glyco-cholate and tauro-
cholate of soda for the bile.

These substances first make their appearance in the substance of the
gland itself ; they do not pre-exist in the blood ; they are discharged from
the gland for a special purpose, and when there is no necessity for their
action, the discharge does not take place. Illustrations of this are to be
found in the digestive fluids, which are true secretions ; only poured out
when this function is called into action by the ingestion of food, and not
discharged from the body, but their elements taken up again by the blood
when their function is accomplished. Thus the gastric or pancreatic fluids
are never secreted until food is taken into the alimentary canal, and are
resorbed with the digested matters.

332 Flint, Jr., New Excretory Function of the Liver. [Oct.

The flow of the secretions is intermittent, and the gland, during the
period of repose, manufactures the elements of the secretion, which are
washed out at the duct when the appropriate stimulus (of food, for exam-
ple) causes a determination of blood to the organ. The gland manufactures
the elements of the secretion, and the blood furnishes the menstruum, the
water, by means of which they are dissolved and emptied into the duct. If
we expose the pancreas of an animal during the intervals of digestion, it is
pale and bloodless ; no fluid flows from the duct; but the elements of the
pancreatic juice are, nevertheless, in the gland, for if we macerate it in
v/ater, we may dissolve them out, and make an artificial pancreatic juice
which will have all the reactions and digestive properties of the natural
secretion. But if we expose the pancreas of an animal during digestion,
the gland is turgid with blood ; the secretion flows from the duct, and the
products of the gland are being washed out by the blood — a process which
we imitated when we dissolved them out by maceration in water. The late
brilliant experiments of Bernard have shown that the function of the glands
is regulated by the nervous system, and that the galvanization of certain
nerves, by which the nervous force is imitated, will cause a determination
of blood to the organ, and induce secretion, while the galvanization of other
nerves will contract the vessels, and arrest secretion.

The substances which characterize the secretions, as they are manufac-
tured in the glands and do not pre-exist in the blood, do not accumulate in
the blood when the gland is removed, or its functions are interfered with.

The distinctive characters of the secretions, in fact, may be summed up
thus : —

Their elements first appear in the glands, and do not pre-exist in the
blood. They are not discharged from the body (with the exception of the
milk, which is destined for the nourishment of the child). Their flow is
intermittent. They are destined to assist in some of the nutritive functions
of the body.

Excretions, of which the urine may be taken as a type, have entirely
different characteristics.

Excrementitious substances do not first make their appearance in the
organs which separate them, but are produced in the general system.

They pre-exist in the blood, having been absorbed by this fluid from the
parts of the system in which they are formed, are carried to particular
organs, and separated from the blood for the sole purpose of being expelled
from the body. An illustration of this is to be found in the urea, which
has been detected in the blood and urine, and some of the tissues of the
body. This substance, one of the most important excrementitious products,
is absorbed by the blood from certain parts of the system., carried to the
kidneys, there separated from the blood, and discharged from the body.
Though the gastric and pancreatic fluids, and all the secretions proper, are

1862.] Flint, Jr., New Excretory Function of the Liver. 333

resorbed with the food after thej^ have acted upon it, the urea may remain
any length of time in the bladder, but it is never absorbed.

The flow of the excretions is constant. No period of repose is necessary
for the gland to manufacture their elements, as they all pre-exist in the
blood. Nutrition is constant, and destructive assimilation, or waste, which
necessitates nutrition or repair, is likewise constant. The blood supplies
all the wants of the system, and receives all the products of its decay. As
the blood is continually being impoverished, it must be regenerated from
without ; and this is done by food, which is prepared for absorption by
digestion. The secreted fluids are mostly concerned in digestion, and as
this is an occasional process, the secretions are intermittent. But waste is
continually going on, and excrementitious substances are continually form-
ing ; and while the necessity for the secretions is occasional, the necessity
for the excretions is constant. Though the actual discharge of the latter
from the body is occasional, they are constantly being separated from
the blood, and accumulate in receptacles, whence they are discharged at
appropriate intervals. No such receptacles exist for the secretions proper,
except in the instance of the milk, which accumulates in the ducts of the
mammary gland, and is the only secretion which is discharged from the
body.

If the secreting glands take on an excretory function, as is an occasional
pathological occurrence, their flow becomes continuous. We have an ex-
ample of this in the occasional separation of the urea from the blood by the
gastric tubuli. When the kidneys become so affected by disease as to be
unable to separate the urea from the system, the accumulation of this ex-
crement in the blood frequently induces other organs to attempt its re-
moval. The gastric tubuli take on that function, and produce a fluid which
contains urea. The gastric juice, if we may now so term it, is no longer a
secretion, but an excretion, and we find that its flow is no longer intermit-
tent and dependent upon the stimulus of food introduced into the stomach,
but is constant, and continues until the irritation caused by the decomposing
urea in the stomach induces an inflammation which prevents further secre-
tion. Thus we have an example of an intermittent secretion, characterized
by a substance manufactured in the gland and not pre-existing in the blood,
changed into a constant exci^etion, characterized by a substance which is
not manufactured in the gland but pre-exists in the blood.

The substances which characterize the excretions accumulate in the blood
when the organ which eliminates them is removed, or its functions are in-
terfered with. It is to this fact that we owed our knowledge that urea
pre-existed in the blood. It was detected in that fluid when it had accn-
mulated'in animals from which the kidneys had been removed, and in cases
of Bright's disease of the kidneys, before our chemical processes were suffi-
ciently delicate to detect it in healthy blood, when the quantity is kept
down to a very low standard by its constant elimination by the kidneys.

334 Flint, Jr., New Excretory Function of the Liver. [Oct.

The characters of the excretions, then, are entirely opposite to those of
the secretions.

Their elements pre-exist in the blood, and are not manufactured in the
substance of the organs which eliminate them. Their flow is constant.
They are separated from the blood merely to be discharged from the body,
and are not destined to assist in any of the nutritive functions of the body.

Having thus contrasted the secretions and the excretions, let us examine
the bile and note what are the characters which it has in common with
either or both of these products.

The bile is characterized by two kinds of principles. One of them, the
glyco-cholate and tauro-cholate of soda, manufactured in the liver, found
in no other fluid than the bile, does not pre-exist in the blood, and asso-
ciates the bile with the secretions. The other, the cholesterine, pre-exists
in the blood and is simply separated from it by the liver, giving the bile
one of the characters of an excretion.

The biliary salts (the glyco-cholate and tauro-cholate of soda) "are dis-
charged into the intestinal canal for a special purpose ; and this discharge
takes place at the beginning of the digestive act. If we expose the liver
and gall-bladder of a dog which has not taken food, we will find the gall-
bladder distended with bile; but if we examine these organs when digestion
is going on, the gall-bladder will be found nearly empty. It is true that
after prolonged fasting the bile is discharged into the alimentary canal, but
it must be remembered that it contains another ingredient, the cholesterine,
which must be discharged from the body, as we will see presently. The
biliary salts are not discharged from the body. Dr. Dalton has shown
that the substances extracted from the contents of the large Intestine by
evaporation, extraction of the residue with alcohol and precipitation with
ether, will not react with Pettenkoffer's test, which is a very delicate test
for the biliary salts. I have treated the feces of the human subject in the
same way with the same result. These salts, therefore, are not discharged
from the body unchanged. The next question to determine is whether they
are discharged from the body in a modified form. They contain a certain
amount of sulphur, of which, as has been shown by Bidder and Schmidt,
only one-fifteenth part of the entire quantity which enters the intestine
with the bile can be detected in the feces. As sulphur is an elementary
substance, it cannot be decomposed ; and the biliary salts, in this passage
down the alimentary canal, must be absorbed. It is true that these salts
cannot be detected in the blood coming from the intestines, but we cannot
detect the pancreatine of the pancreatic juice, the pepsin or lactic acid of
the gastric juice in the portal blood, yet these are absorbed by the mucous
membrane of the intestinal tube, changed by their union with the elements
they have digested. It is probable that an analogous change takes place
in the glyco-cholate and tauro-cholate of soda, which prevents them from

1862.] Flint, Jr., ]N'ew Excretory Function of the Liver. 335

being detected in the blood by the ordinary tests. These facts, also, place
the bile among the secretions.

On the other hand, cholesterine pre-exists in the blood, having been ab-
sorbed by this fluid from certain, parts of the system, is carried to the liver,
and here separated for the sole purpose of being discharged from the body.
The same general remarks apply to this substance as to the urea. This
places the bile among the excretions.

The flow of the secretions is intermittent. This is not absolutely true of
the bile, but the discharge of this fluid is remittent. Dr. Dalton^ has re-
ported a series of interesting experiments upon an animal with a duodenal
fistula. In this observation ten grains of dry biliary matter were discharged
into the duodenum of a dog weighing thirty-six and a half pounds, imme-
diately after feeding. At the end of the first hour it had fallen to four
grains; it continued at three and a half to four and a half grains up to
the eighteenth hour, when the quantity was inappreciable ; at the twenty-
first hour it was one grain, the twenty-fourth, three and a quarter grains,
and the twenty-fifth three grains. The fluid was drawn for fifteen minutes
each time, evaporated to dryness, extracted with absolute alcohol, precipi-
tated with ether, the ether precipitate dried, and weighed as representing
the quantity of biliary matter present. These experiments apply to the
time when the bile is discharged into the intestine ; but as most animals
have a gall-bladder, which collects the bile as it is secreted, it does not
show when this fluid is formed by the liver. Schv/ann, Bidder and
Schmidt, Arnold, KoUiker, and Miiller, have made experiments bearing
upon the latter point, by ligating the ductus communis choledochus and
making a fistula into the fundus of the gall-bladder. The experiments of
these observers vary somewhat with regard to the time when the secretion
of the bile is at its maximum. In the animal referred to on page 308,
in which a fistula was made into the fundus of the gall-bladder, the bile
was collected for thirty minutes immediately after feeding, one hour after,
and then at intervals of two hours during the remainder of the twenty-four
hours. The specimens of bile thus collected were carefully weighed, evapo-
rated to dryness, and the proportion of dry residue taken. The accom-
panying table shows the results of these observations, which were made
twelve days after the operation, when the animal, which weighed originally
twelve pounds, had lost two pounds. His appetite was ravenous at the
time of the experiment.

' Dalton ou tlie Constitution and Plijsiology of the Bile. Loc. cit.

336 Flint, Jr., New Excretory Function of the Liver. [Oct.

Table of the variations of the bile in the twenty-four hours. At each
observation the bile was drawn for precise!}' thirty minutes. Dog with
a fistula into the gall-bladder. Weight ten pounds.

1 11116 (tllGr x 6Gu.lIl^.

r 1 (3.SI1 Olie.

Percentage of
Dry Residue.

grains.

Immediately

8.103

0.370

4.566

One hour ....

20.527

0.586

2.854

Two hours ....

35.760

1.080

3.023

Four hours ....

38.939

1.404

3.605

Six hours ....

22.209

0.987

4.450 ■

Eight hours ....

36.577

1.327

3.628

Ten hours ....

24.447

0.833

3.407

Twelve hours

5.710

6.247

4.325

Fourteen hours

5.000

0.170

3.400

Sixteen hours

8.643

0.309

3.575

Eighteen hours

9.970

0.277

2.778

Twenty hours

4.769

0.170

3.5G5

Twenty-two hours .

7.578

0.293

3.868

Twenty-four hours

15.001

0.885

5.233

This table shows a regular increase in the quantity of bile discharged
from the fistula from the time of feeding up to four hours after. It dimin-
ished at the sixth hour, rose again at the eighth hour, but then gradually
diminished to the fourteenth hour. We then have a slight increase the
sixteenth and eighteenth hours, and the twentieth hour it falls to its mini-
mum. It then increased slightly the twenty-second hour, and mounted
considerably the twenty -fourth hour, when the observations were concluded.
Disregarding slight variations in the quantity, which might be accidental,
it may be stated in general terms, that the maximum foiv of bile from
the liver is from the second to the eighth hour after feeding; during ivhich
time it is about stationary. In this experiment it was at its minimum
the twentieth hour after feeding. This observation agrees with those of
Bidder and Schmidt as regards the time when the bile begins to increase in
quantity ; but these observers state that it is at its maximum at the twelfth
to the fifteenth hour. This, however, is not material to the question now
under consideration. We wished to establish the fact that the quantity of
bile secreted varied considerably during the various stages of the digestive
act; a character which approximates it to other secretions. The flow of the
bile is not intermittent, because it contains a substance which is excremen-
titious; but it is remittent, having a definite relation to the digestive act,
because it contains substances which are recrementitious and are in some
way connected with the process of digestion.

The continuous, though remittent, flow of the bile allies it with the ex-
cretions. There is no time, in health, when the bile is not separated from
the blood. In animals that go through the process of hibernation, the bile
continues 'to be secreted, though no food is taken into the alimentary canal.
Nutrition, though much diminished in activity, goes on during this state,

1862.] Flint, Jr., New Excretory Function of the Liver. 33t

and the urea and cholesterine must be separated from the blood. The forma-
tion of the bile and urine, therefore, is not interrupted. The bile is secreted
also in the foetus, before any nourishment is taken into the alimentary canal,
when none of the other digestive fluids are formed. This character it has
in common with the urine, and this places it among the excretions.

The elements of secretion never accumulate in the system when the secre-
tion is interfered with ; while the elements of excretion do accumulate in the
blood in such cases, and produce their toxic effects. Experimenters have
often analyzed the blood for the biliary salts in cases of serious disease of
the liver, marked by symptoms of bile poisoning, regarding these as the
only important elements of the bile ; but they have never been detected. I
have made no observations on this point, for the fact that the glyco-cholates
and tauro-cholates of soda do not accumulate in the blood in diseases of the
liver has long been settled. This stamps these substances as products of
secretion; but we will see when some of the pathological conditions of the
cholesterine are taken up, that this substance does accumulate in the blood
when the functions of the liver are seriously interfered with, which marks
it as a product of excretion.

It seems to me that enough has been said with regard to the function of
the bile to convince the reader that this complex fluid has two important
elements which have two separate functions.

First. It contains the glyco-cholate and tauro-cholate 'of soda; which are
not found in the blood, are manufactured in the liver, are discharged
mainly at a certain stage of the digestive process, are destined to assist
in some of the nutritive processes, are not discharged from the body, and,
in fine, are products of secretion.

Second. It con tains cholesterine; which is found in the blood, is merely
separated from it by the liver, and not manufactured in this organ, is
not destined to assist in any of the nutritive processes, but merely sepa-
rated to be discharged from the body, and is a product of excretion.

These two propositions, and more especially the second, being established,
it becomes our task now to follow out the cholesterine after it has been
discharged from the liver into the small intestine. If it be discharged from
the body it must be by the rectum, and to complete the history of choles-
terine we find it necessary to study the feces.

The Feces. — It is not my object to consider all the effete matters which
go to make up the feces, though it must be acknowledged that our infor-
mation on this subject is very limited. Following the cholesterine in its
passage down the alimentary canal has opened a new subject for investiga-
tion, which it will be impossible to do entire justice to in this paper. There
is a field for a long series of investigations into this part of our subject,
which I hope to be able to cultivate to some extent in the future, and add
something to the history of the substance we have been considering. At
present I shall only endeavour to demonstrate the fact that cholesterine, in
No. LXXXYIIL—OcT. 1862. 22

338 Flint, Jr., New Excretory Function of the Liver. [Oct.

a modified form, is discharged with the feces, and not attempt to treat of
the conditions which modify the excretion of this substance (upon which as
yet I have no data), which are of the last importance to the practical phy-
sician.

It is stated by some of the most reliable authors on physiology and physio-
logical chemistry that cholesterine is found in the fecal matters. Robin and
Yerdeil say, "Ce principe immediaf se trouve d Vetat normal dans le sang,
la bile, lefoie, le cerveau, les nerfs, le crystallin et les matieres fecales.^^
Many other authors refer to it as found in the feces, and it was with that
belief, that, in the experiments which form the basis of this article, I deferred
my analyses of the feces till I had completed the observations on the blood,
and then analyzed them, satisfied that I would find cholesterine, with the view
to determine the variations, etc., in its quantity. When after a careful and
prolonged examination of many specimens of feces I was unable to extract
any cholesterine, I endeavoured to ascertain what observer had established its
presence. Though it is mentioned by so many as present in the feces, I could
find no mention of any one who had established this point; and in some of
the analyses of Simon, I found that he had noted its absence in certain speci-
mens of feoes. I found also that Marcet, who published some elaborate
analyses of the feces in Philosophical Transactions, in 1854 and 185t,
noted the absence of cholesterine in the normal feces of the human subject.
We have already seen how conclusively the experiments on the blood from
various parts of the system point to the excrementitious character of the
cholesterine, showing us even in what part of the system it is found, and
where it is eliminated ; but it is undoubtedly one of the most important
characters of an excretion that it should be discharged from the body,
and I was unable for a time to convince myself that it was discharged.
After evaporating the feces to dryness, pulverizing, extracting thoroughly
with ether, decolorizing with animal charcoal, evaporating the ether
and extracting the residue with boiling alcohol, I allowed the alcohol to
evaporate, added a solution of caustic potash, and kept the mixture at a
temperature near the boiling point for three and a quarter hours. The
potash was then carefully washed away in a filter, the residue redissolved
in ether and extracted with hot alcohol as before, and the alcoholic extract
set aside to evaporate. A number of days passed without any signs of
■crystallization. The residue was, of course, non-saponifiable; but it differed
from the cholesterine by being melted at a much lower temperature, though
it presented the red colour with sulphuric acid which is said to be charac-
teristic of the latter substance. It was examined carefully with the micro-
scope daily, and after five or six day^, to my great satisfaction, crystals
began to form ; but they were at first so indistinct that their form could
not be clearly made out. These crystals, however, increased in size and
number, and in a short time presented all the characteristics of seroline.
In about ten days the whole mass had crystallized, making one of the most

1862.] Flint, Jr., New Excretory Function of the Liver. 339

superb exhibitions of crystals that could be imagined. The seroline crys-
tallizes in the form of delicate transparent needles, which have a beauty
under the microscope which could be but poorly imitated by the most deli-
cate steel plate engraving. This substance, from its being found in such
large quantity in the feces, 1 have spoken of as stercorine.

Before taking up the changes which the cholesterine undergoes in its pass-
age down the alimentary canal, I will say a few words with regard to the
stercorine, which will play an important part in this connection.

Stercorine.

The stercorine has already been referred to and delineated in the analyses
of various specimens of blood for cholesterine. It was discovered by
Boudet, and described by him under the name of seroline, in an article pub-
lished in the Annales de Ghimie et de Physique, in 1833, as a principle
found in the serum of the blood. Up to the present time, this is the only
situation in which it has been found, and here in such an excessively minute
quantity that enough has never been obtained for ultimate chemical ana-
lysis. With regard to its function nothing whatever has been known.
Robin thus speaks of it: " On ne sait pas comment se forme la seroline,
ni quel est son role physiologique.^^^

Chemical characters. — This substance, like cholesterine, is a non-saponi-
fiable fat. It has never been obtained in sufficient quantity for ultimate
chemical analysis ; but as in its decomposition it disengages a little am-
monia, it is supposed by Yerdeil and Marcet to contain nitrogen.^ The
evidences of this ingredient are very slight, and its existence is doubtful.
It is neutral, inodorous, insoluble in water, soluble in ether, very soluble in
hot alcohol, but almost insoluble in cold. It is not attacked by the caustic
alkalies, even after prolonged boiling. When treated with strong sulphuric
acid it strikes a red colour, similar to that produced by the sulphuric acid
and cholesterine. According to Lehmann it melts at 96° 8' Fahr., and on
the application of strong heat may be distilled without change. Boudet
extracted it from the serum of the blood, by evaporating it, boiling the
residue with water, and evaporating again, taking up the residue with
boiling alcohol, which deposited the crystals on cooling.

Form of its crystals. — Boudet describes the crystals thus obtained as
filaments, with varicosities here and there, which gave them a beaded ap-
pearance. Lecanu also observed this peculiarity. In the atlas of Robin
and YerdeiPs Anatomical Chemistry we have a beautiful representation of
the crystals of seroline from the blood. These observers have not noticed
the beaded appearance mentioned by Boudet, but represent the crystals in

1 Robin and Verdeil, CMmie Anatomique et Plijsiologique, tome iii. p. 66.

2 Cours de Physiologie fait la Faculte de Medecine de Paris. Par P. Berard,
Professeur de Physiologie, &c., tome iii. p. 118. Paris, 1851.

340 Flint, Jr., New Excretory Function of tlie Liver. [Oct.

the form of delicate transparent needles, of variable size, some very small
and others quite wide, terminating in a fine pointed extremity, which in
some of the wider crystals is bifurcated, or even trifurcated, with the edges of
the larger crystals frequently split, as it were, into delicate filaments. The
smaller crystals frequently arrange themselves in a fan shape. Robin and
Yerdeil attribute the beaded appearance mentioned by Boudet and Lecanu
to the presence of little globules of fatty matter mixed with the crystals.
This seems probable, for we shall see when we examine the process of
extraction employed by Boudet, that he probably did not succeed in obtain-
ing it in a pure form. The appearance of these crystals has already been
given in some of the diagrams of cholesterine, especially in Figs. 2, 6, 7,
and 9. I have been able to follow the process of crystallization in the
specimens extracted from the feces from its commencement, and have found
that the splitting of the ends and edges of the crystals did not take place
at first. The needles which were first found had regular borders -and single
pointed extremities ; but after a few days they split up in the manner
described and figured by Kobin and Yerdeil. (See Figs. 14 and 15.)

Situations. — Up to this time the seroline (or stercorine) has only been
found in the serum of the blood, and there in but very small quantity, the
proportion being, according to the analyses of Becquerel and Rodier, 0.020
to 0.025 of a part per 1,000 parts of blood. They have seen it mount up
to 0.060 parts, and descend to a quantity almost inappreciable.'^

Process of extraction. — In the first observations I made on the blood
this substance was observed before the cholesterine. In these observations
the blood was dried, pulverized, extracted with ether, the ether evaporated,
the residue extracted with boiling alcohol, and then a solution of caustic
potash added, which remained on the specimens for a number of days. In
ail the subsequent analyses of the blood the cholesterine was extracted per-
fectly pure, and no stercorine whatever was observed. The following was
the diiJerence in the modes of analysis. In the latter case the solution of
potash was not allowed to remain on the specimens more than an hour or
two ; but was washed away, and the residue, which was left on the filter,
redissolved in ether. The failure to detect the stercorine in all the later
observations on the blood, which are twenty-four in number, inclines me to
the opinion that it does not primarily exist in that fluid ; and that when it
has appeared in the extract it has been due to a transformation of a portion
of the cholesterine. This view seems the more probable, as I have definitely
ascertained by observations on the feces, which will be detailed farther on,
that the cholesterine is capable of being changed into stercorine, and that this
change actually takes place before it is discharged from the body. In my
observations on the blood no attempt was made to get rid of this substance,

1 Traite de Chimie Pathologiqne Appliquee la Medecine Pratique. Par M. Alf.
Becquerel and M. A. Rodier, p. 62. Paris, 1854.

1862.] Flint, Jr., New Excretory Function of the Liver. 341

and though it is soluble in the menstrua luhich ivere used to extract the
cholesterine, and not destroyed by any of the means that ivere employed to
purify the cholesterine, it never appeared in the extract. In these experi-
ments the study of the stercorine in the blood has not been attempted ; and
though it is not possible to state at present how the cholesterine was trans-
formed in the first observations, it seems most rational to suppose, in en-
deavouring to explain its absence in the twenty-four succeeding specimens
of blood which were examined, that such a change had taken place.

I am inclined to the opinion, then, though I cannot state it positively,
that the element under consideration does not exist in the blood as a
proximate principle, but is formed from the cholesterine, in some unex-
plained way, by the processes which have been used for its extraction.^
This transformation does not take place during the extraction of this sub-
stance from the feces, because I have in but a single instance been able to
extract cholesterine by the processes which are successful in obtaining it in
other situations in which it exists, including the meconium.

The stercorine may be extracted from the feces in the following way :
The feces are evaporated to dryness, pulverized and treated with ether,
which should be allowed to remain from twelve to twenty-four hours, pro-
tected from evaporation. The ether is then separated and decolorized by
filtration through animal charcoal, fresh ether being added till the original
quantity has passed through. It is impossible to decolorize the solution
entirely, but it should be made to pass through of a very pale amber tinge
and perfectly clear. The ether is then evaporated and the residue extracted ,
with boiling alcohol. The alcohol is then evaporated and the residue
treated with a solution of caustic potash, at a temperature a little below
the boiling point, for from one to two hours. This dissolves all the sapo-
nifiable fats, and the solution is then largely diluted with water, thrown
on a filter, and washed till the fluid which passes through is perfectly clear
and neutral. The filter is then dried at a moderate temperature, and the
residue washed out with ether, which is evaporated, extracted with boiling
alcohol, and evaporated again. The residue is composed of pure stercorine.
The extract thus obtained is a clear, slightly amber, oily substance, of
about the consistence of the ordinary Canada balsam used in microscopic
preparations, and in four or five days begins to show the characteristic

1 As we have no ultimate analysis of this substance, it is impossible to enter
into any chemical speculations with regard to the change from cholesterine, as we
may in the instance of the creatine and creatinine, or the urea and carbonate
of ammonia.

' As this substance is said to be volatilized at a high temperature, it is impor-
tant, in our examination, to avoid as much as possible the application of heat.
Large quantities of it are extracted from the feces after evaporation over an ordi-
nary water bath, but it might be better to evaporate the excrements at a lower
temperature.

342 Flint, Jr., New Excretory Function of the Liver. [Oct.

crystals. These are at first few in number; but soon the entire mass
assumes a crystalline form. In a specimen which I have extracted from
the feces I have 10.417 grains, consisting, apparently, of nothing but crys-
tals. If the extract be evaporated in a very thin watch-glass it may be
examined with the microscope daily, and the process of the formation of
the crystals observed. These crystals, after they are fully formed, may be
examined satisfactorily with a half or quarter inch objective.

History of seroline. — Yery little is to be said with regard to the his-
tory of this substance. Boudet first described it in 1833.^ Lecanu con-
firmed these observations in 1837.^ Since then it has been studied by
Becquerel and Rodier,^ Chatin and Sandras,* W. Marcet and Yerdeil.^
Gobley states, in an article published in the Journal de Chimie Medi-
cale, that the substance described by Boudet is not an immediate principle
but a mixture of several substances, confounding it, however, with choles-
terine.^ Bobin and Yerdeil adopt this view, but consider it entirely differ-
ent from the cholesterine.''

This element, existing, as it does, in large quantities in the fecal matter,
must take its place among the important excrement! tious substances dis-
charged from the organism, not second in importance even to the urea. It
is a curious fact that while the urea was known as an ingredient of the
urine long before it could be demonstrated in the blood, taking its name
from that fluid, we have the stercorine, an excrement of great importance,
discovered in the blood and never till now recognized as an excrement and
V an ingredient of the feces, taking a name from the serum of the blood,
which does not indicate at all its excrementitious properties nor the situa-
tion in which it is found in greatest abundance. As seroline has been
heretofore a substance of very little prominence, and as it probably does
not exist normally in the serum of the blood, and if at all, in insignificant
quantity, the application seems a misnomer. We want a name which will
indicate its excrementitious properties, and the channel by which it is
evacuated, and I have adopted the name Stercorine^ as more appropriate
and more suggestive of its properties, as it is undoubtedly the most im-
portant excrement discharged by the anus.

The questions which now arise with regard to this substance open a
field of inquiry too extensive, by far, to be thoroughly investigated in the

1 Boudet. Loc. cit.

2 Lecanu. Etudes cMm. sur le sang humain, these. Paris, 1837, page 55.

' Becquerel and Rodier. Recherches relatives a la comp. du sang. (Comptes
Rendus. Paris, 144, tome xix. p. 1084.)

* Chatin et Sandras. Gaz. des hopit., 1849, page 289.
^ Berard. Loc. cit.

^ Gobley. Sur les matieres grasses du sang. (Journal de Chimie Medicale, 1851.
Paris, page 577.)

'' Robin et Verdeil. Loc. cit. ^ From Stercus, oris, dung.

1862.] Flint, Jr., New Excretory Function of the Liver, 343

time that could be devoted to this subject, or to be discussed in the limits
of this paper. We wish to know the entire history of this product ; the
quantity discharged in twenty -four hours ; variations that may take place
with season, age, sex, diet, digestion, &c. ; and more especially, the modifi-
cations which occur in its discharge in connection with diseased conditions.
These points are of great importance, but require a long and laborious
series of investigations for their elucidation. What has been done in a
measure for the urea must be done for the stercorine, before we can arrive
at a precise idea of its relations to disease. For this purpose a large num-
ber of quantitative analyses of healthy feces must be made and compared
with similar analyses in different diseases. At present I have only instituted
a sufficient number of examinations to substantiate the statements I have
made with regard to the formation and discharge of this substance, and
added a few examinations of feces in disease which bear upon the same
points. I hope at some future time to go more fully into the study of the
feces, and contribute something towards the elucidation of some of the
questions which naturally arise. In the mean time I present the following
observations on the stercorine as it appears in the feces.

Exp. 9. Seven and a half ounces of feces, perfectly normal in appear-
ance, and being the entire quantity passed in the morning at the regular
time for an evacuation, were taken from a healthy male, twenty-six years
of age. After being evaporated, and pulverized finely in an agate mortar,
the residue weighed 2 oz. 51.318 grains. A small quantity was then ex-
tracted with alcohol, the solution being of a yellow colour, and about six
times its volume of ether added. The ether was filfbred after standing for
fifteen minutes, the filter Avashed with distilled water, and the solution
tested with Fettenkoffer's test for the* biliary salts. None of these salts
were present.

A watery solution was then made of another portion, which was filtered
and tested with nitric acid, but failed to show the reactions of the colour-
ing matter of the bile.

The dry residue was then treated with five fluidounces of ether for
twenty hours, when it was filtered through animal charcoal, fresh ether
being added till the fluid which passed through made five ounces. It came
through perfectly clear and of a very light golden tinge. It was then
evaporated, leaving a golden yellow fat with a number of whitish resinous
masses. It was then extracted with f5iss of boiling alcohol, which
removed everything but a small quantity of bright yellow oil, and filtered
while hot. It became turbid on cooling, and was set aside to evaporate.
Both the ethereal and alcoholic extracts had a very offensive rancid odour.
The residue, after the evaporation of the alcohol, consisted of a consider-
able quantity of fat of a yellowish colour and a consistence like thick tur-
pentine. It was then treated with a solution of caustic potash, kept near
212° for about thirty minutes and allowed to stand for twenty hours. At
the end of that time a large quantity of fat floated on the top of the fluid
not at all affected by the alkali. It was then largely diluted with distilled
water filtered and washed, the filter dried, and the residue redissolved in
ether. This ethereal solution was evaporated and the residue extracted
with boiling alcohol as before. After the alcohol had evaporated, a small

344 Flint, Jr., New Excretory Function of the Liver. [Oct.

quantity was treated with sulphuric acid which produced a peculiar red
colour similar to that produced when the acid was added to a specimen of
cholesterine, extracted from the blood and used for purposes of comparison.

Five days after, the specimen was examined with a y%th inch objective,
and presented some crystals which looked like seroline; but it was im-
possible, on account of the thickness of the glass capsule to apply a suffi-
ciently high power to make this certain. Some long, pale, radiating crys-
tals were observed, composition unknown, but they were not the crystals of
excretine described by Marcet.^ The specimen was treated again with a
solution of caustic potash and kept at nearly the boiling point of water for
three and a quarter hours, most of the fat floating on the top of the fluid
in white flakes and yellow drops, but a considerable quantity undergoing
saponification, as evidenced by the colour of the potash solution. The
potash was then removed by filtration, the residue dissolved in ether and
extracted with boiling alcohol as before.

Four days after the evaporation of the alcohol a large number of the
characteristic crystals were formed. These did not have the split extremities
and edges noted by Robin, but terminated in a single point, and had
regular borders ; these crystals are represented in Fig. 14.

In a few days the entire mass had assumed a crystalline form, and the
crystals then presented split extremities and borders such as are mentioned
by Robin. (See Fig. 15.)

The quantity of the stercorine was 10.411 grains.

Exp. 10. Another analysis was made of the feces from the same individual.
During the experiment a large quantity was unfortunately lost, and the
examination, therefore, was not quantitative. The presence of stercorine
was established.

Exp. 11. The feces of the dog from which blood of the carotid and
-*

1 Marcet, in two papers publislied in tlie Philosophical Transactions, for 1854 and
1857, describes a new proximate principle in the feces which he calls Excretine.
This he obtains in the following way : He first treats the feces with boiling alcohol
till nothing more can be extracted. A sediment deposits from the alcohol on cool-
ing. The alcoholic solution is acid. Milk of lime is added to the solution, which
gives a yellowish brown precipitate, leaving a clear, straw-coloured fluid. The
precipitate is then collected on a filter, dried, afterwards agitated with ether, and
filtered, forming a clear yellow solution. In 'from one to three days beautiful
silky crystals collect in masses, or tufts, adhering to the sides of the vessel, throw-
ing out ramifications in every direction. These, viewed under the microscope, are
in the form of acicular, four-sided prisms, and this substance is called by Dr.
Marcet, Excretine, and is found nowhere but in the feces. It is soluble in ether
and hot alcohol, sparingly so in cold alcohol, and insoluble in hot or cold water.
It does not crystallize from an alcoholic solution on cooling, but crystallizes from
ether. When suspended in boiling water it fuses into resinous masses, and floats
on the top. Its fusing point is 203o to 205O Fahr. It may be boiled for hours
with potash without undergoing saponification.

In the article published in 1857, Dr. Marcet gives the composition of the Excretine
C78 02 SI.

There is no similarity between the form of the substance described by Marcet
and the stercorine. Its high fusing point, 203O to 205© Fahr., and its crystalliza-
tion from an ethereal solution, also serve to distinguish it from the stercorine, which
uses at 960.8 Fahr., and does not crystallize in an ethereal solution.

1862.] Flint, Jr., New Excretory Function of the Liver. 345

internal jugular on one side had been taken fifteen days before, the animal
having entirely recovered, were examined. The analysis was not quantita-
tive. The feces were treated in the way already described, and the pre-
sence of stercorine determined.

Exp. 12. A specimen of feces voided by a healthy dog, fasting, was
examined in the usual way for stercorine. After the final extract had
evaporated, it was examined microscopically, and found to contain, in
addition to the stercorine, a considerable quantity of cholesterine, crys-
tallized in beautiful tablets. This is the only examination of feces in
which I have found cholesterine. The proportion of stercorine and choles-
terine was as follows : —

Quantity of feces 137.513 grains.

Stercorine with a little cholesterine . . . 0.216 " ^

These examinations of the feces in health show that they invariably
contain a non-saponifiable fatty substance known under the name of sero-
line, but which I have called stercorine. In but one of these analyses, the
last, did I find any cholesterine, though the first were originally under-
taken with a view to the extraction of this substance.

The stercorine has never before been detected in the feces, and, as far as
my knowledge of its physiological properties is concerned, may be consi-
dered a new substance ; the discovery of which, in this situation, marks it
as one of the most important of the products of destructive assimilation.
The next question which arises, then, is with regard to its origin.

Origin of the stercorine. — In our study of the chemical properties of
this substance, we have already seen that it is one of the non-saponifiable
fats, having many characters in common with the cholesterine. It has been
described, under the name of seroline, as existing in the blood, in very
minute quantity, but does not exist in any of the fluids which are poured
into the alimentary canal. The cholesterine, however, which it so closely
resembles, is one of the constituents of the bile. The fact that the choles-
terine is discharged into the small intestine, and not usually found in the
evacuations, while stercorine is abundant, would at once point to a possible
connection between these two substances. In most cases, in health, cho-
lesterine disappears, and stercorine is found; but in some rare instances,
as in the single examination of dogs' feces, Exp. 12, the two substances
coexist in the evacuations, the stercorine, in the example just mentioned, in
much the greater quantity. The question then arises : Is the cholesterine
capable of being converted into stercorine, and does the latter substance
originate from a transformation of the cholesterine of the bile ? Before
we treat of this subject experimentally, let us examine the facts which we
already have bearing on this point. No examinations of the feces have
ever been made for stercorine, but under certain circumstances cholesterine
has been found discharged by the anus without alteration.

Cholesterine has been detected in the meconium, in the feces of hiber-
nating animals, and occasionally in ordinary feces, though I can find no
observation of this kind but the one just recorded.

346 Flint, Jr., 'New Excretory Function of the Liver. [Oct.

Meconium. — Cholesterine exists in the meconium in considerable quan-
tity, where it may be seen in tablets by a simple microscopic examination,
aud from which it may be extracted in quantity, and with great facility.
The stercorine, or seroline, has never been mentioned as existing in this
situation. In the single examination I have made of the meconium I found
an abundance of cholesterine, 6.245 parts per 1,000, but no stercorine.
There is no difficulty in explaining the origin of the cholesterine in the
meconium. Long before any food is taken into the alimentary canal, and
before the exclusively digestive fluids are formed, the bile is formed and
discharged. It accumulates in the intestine, with other matters constituting
the meconium, and is finally evacuated soon after birth. Hence the choles-
terine exists in large abundance ; but when the digestive fluids are secreted,
and food is received into the alimentary canal, the cholesterine is lost and
the stercorine makes its appearance.

Feces of liiberiiating animals. — As the excreting function of the liver
commences before food is taken into the alimentary canal, so it goes on
during the state of hibernation, when the animal takes no food for weeks,
or even months. Under these circumstances, the cholesterine is found un-
changed in the feces, but it disappears when the animal arouses, aud the
digestive organs resume their functions.

Normal feces. — In the normal feces the cholesterine is generally absent;
but in Exp. 12, it was found in small quantity, mixed with stercorine.
This animal had been certainly twenty-four hours, and probably forty-eight
hours, without food. The feces were of normal colour and consistence.

These facts seem to show that before digestion commences, as in the
foetus, and when it is suspended, as in hibernating animals and in Exp.
12, cholesterine passes through the alimentary canal unchanged. But as
soon as digestion commences, the cholesterine is lost in the feces, and its
place is supplied by stercorine. It seems almost certain, then, that in its
passage down the alimentary canal, the cholesterine of the bile is acted
upon by some of the digestive fluids and changed into stercorine. This
change seems to be incident to the digestive act ; for before digestion com-
mences, or when it is suspended, the cholesterine passes through unchanged.
A conclusive observation would be to cut off the bile from the intestines,
and consequently the cholesterine, and notice the effect upon the production
of stercorine. In a case of jaundice from duodenitis (which will be more
minutely detailed in the section on the pathological relations of choleste-
rine), the necessary conditions for this observation seemed to be fulfilled.
The patient suffered from intense jaundice, dependent upon obstruction of
the common bile duct from duodenitis. The feces were clay-coloured. After
a time, the patient was relieved of the jaundice, and the feces regained
their natural colour. While the feces were decolorized, and when the
icterus was most marked, it is probable that the bile was entirely cut off
from the alimentary canal. This condition was relieved, however, when

1862.] Flint, Jr., New Excretory Function of the Liver. 347

the feces regained their colour, and the icterus disappeared. For the pur-
pose of ascertaining the effect of the obstruction to the flow of bile on the
stercorine in the feces, and of the re-establishment of the flow, the stools
were examined chemically during the jaundice, and after the patient had
recovered.

Analysis of decolorized feces. — The quantity of feces examined was
941.4 grains. After evaporation, extraction with ether, and extraction of
the residue left after the evaporation of the ether, with hot alcohol, the
fat, which was very abundant, was entirely saponified by boiling for fifteen
minutes with a solution of caustic potash, showing that neither cholesterine
nor stercorine icas present.

Analysis of feces from the same patient after they had become normal
in colour. — This analysis was made nineteen days after the preceding one.
The quantity of feces was small. The specimen was treated in the usual
way, showing stercorine in the following proportions : —

Quantity of feces 502. grains.

" stercorine 0.34 "

Taken in connection with the facts which have already been cited with
regard to the discharge of cholesterine by the anus, when digestion is not
going on, this observation establishes the origin of the stercorine. It is
produced by a transformation, connected luith the digestive act, of the
cholesterine of the bile. When the cholesterine does not find its way into
the alimentary canal, as was the case in the first analysis of feces, stercorine
is not found in the dejections; when the discharge is re-established, the
stercorine reappears.

Compai^ison of the daily quantity of stercorine discharged, with the
quantity of cholesterine produced by the liver. — The quantity of stercorine
which I extracted from the regular daily feces of an adult healthy male, was
10.41T grains. As there is no cholesterine found in the dejections, this
should represent the entire quantity of cholesterine excreted in the twenty-
four hours. A comparison of this quantity with the estimated quantity of
cholesterine discharged in the day, shows this to be the case.

Quantity of bile in the twenty-four hours (Dalton) . 16.940 grains. ^
" " cholesterine at 0.618 pts. per 1,000 (A. Flint, Jr.) 10.4692 "
" " stercorine discharged {Id.) . . . 10.417 "

Difference . . .052

This insignificant difference of .052 of a grain, at once proves the correct-
ness of the estimate of the daily quantity of bile excreted, the accuracy of the
estimate of the proportion of cholesterine in the bile, and of the quantitative
analysis for the stercorine ; and made, as the three observations were, with-

1 Dalton's Treatise on Human Physiology, 2d edition, page 171.

2 See table, page 362.

348 Flint, Jr., New Excretory Function of the Liver. [Oct.

out the slightest reference to each other, adds the final link to the chain of
evidence in support of the view that the cliolesterine, in its passage down
the alimentary canal, is converted into stercorine, in lohich form it is
discharged in the feces.

The history of the cholesterine thus resolves itself : —

1. Cholesterine is an effet§ material, produced by the destructive assi-
milation of nervous matters, and absorbed by the blood.

2. It is separated from the blood in its passage through the liver, enters
into the composition of the bile, giving this fluid its excrementitious
character.

3. It is poured with the bile into the upper part of the small intestine,
ivhen the pjrocess of digestion induces a change into stercorine; in which
form it is discharged by the feces.

4. Stercorine, the great excrementitious element of the feces, is one of
the most important excrements produced by the waste of the system.

Pathological Relations op Cholesterine. — With the limited data we
have on the subject of the variations in the quantity of cholesterine in health
and disease, it is impossible to do more than merely to open the great subject
of its pathological relations. To a certain extent, all questions in physio-
logy have for an end the elucidation of points in pathology. The practical
physician, who may be the reader of this article, will naturally inquire if
the more definite views which we are now enabled to hold with regard to
the function of the bile be of any use to him in the study and treatment of
disease. It is certain that no addition to our knowledge of the functions
of the healthy body is without its bearings on disease, immediate or re-
mote. What may seem to be simply a matter of interest to the pure phy-
siologist, without apparently any practical bearing, is sure at some time to
be so connected, perhaps, with other advances, as to be useful to the prac-
titioner. But the pathological relations of an important excretion do not
have a practical interest so remote, especially when this function is con-
nected with the liver. Almost from time immemorial, a large number of
diseases have been referred to derangement of the liver, and in their treat-
ment, it has been thought of immense importance to promote the secretion
of the bile. A certain class of remedies supposed to regulate the function
of the bile, has been constantly employed by physicians. At the present
day, these ideas have fallen somewhat into disrepute ; for the enlightened
physician is now accustomed to base his pathological views upon a certain
amount of definite knowledge, and it has been found that both the physio-
logy and the pathology of the bile have been very little understood. The
older practitioners had, as we have now, a certain class of cases character-
ized by a general malaise, and having indefinite symptoms which were at-
tributed to ''biliousness," in which they were in the habit of employing the

1862.] Flint, Jr., IS'ew Excretory Function of the Liver. 349

cholagogues, with mercury at the head, with undoubted success. It is true
that, as our knowledge of disease becomes more accurate, the conditions
which were supposed to indicate "biliousness," have become referred to
other disorders ; but no great advance has been made in the pathology of
the liver, and there are yet many conditions which may be successfully
— though empirically — treated, the true character of which is unknown.
It is on this obscure subject that it is hoped the preceding physiological
investigations will throw some light. To repeat an* illustration made use
of before, a knowledge of the functions of cholesterine, and its history in
the healthy organism, should contribute as much to the pathology of dis-
eases dependent on derangement of thi^ function, as has the development
of the functions of the urea for diseases now known to be dependent or
uremia.

Cholesteremia.

In common with other excrementitious substances, which invariably
exist in the blood in health, if the function of the eliminating organ be
interfered with, accumulation takes place in the blood. This fact has
already been incidentally referred to in treating of the properties of the
cholesterine which allied it to effete substances. It takes place with the
urea ; but cases of uremic poisoning occurred, and patients died in uremic
coma, long before the cause of it was understood. It is the same with the
bile. Ordinary cases of jaundice, which have been called, by Piorry, chole-
mia, are not of a dangerous character ; but there are cases in which jaun-
dice, though less marked as regards colour, is a very different condition.
Here we have evidently the operation of some poison in the blood, and
coma and death from its effects on the brain, follow as in retention of the
urea. Pathologists inquire why there is this difference in the severity
of cases of icterus ? Chemists have analyzed the blood in the hope of ex-
plaining it by the presence of the glyco-cholates and tauro-cholates of soda in
the grave cases, regarding them as the only important constituents of the
bile. But their failure to detect these substances has left the question
still unanswered.

In simple cases of jaundice lue have a resorption of the colouring
'matter of the hile from the excretory passages.

In grave cases of jaundice, ichich almost invariahJy terminate fatally,
we have a retention of the choleste^nne in the blood, or cholesteremia.

I have been forced to make use of cases of disease exclusively in studying
this condition, for no one has yet been able, in the larger animals, to extir-
pate the liver, as we do the kidneys, notice the symptoms of poisoning, and.
demonstrate the accumulation of cholesterine in the blood. Nor have I yet
been able, on account of the insolubility of the cholesterine, to make experi-
ments by injecting it into the circulation. I had, however, an opportunity
of making an examination of the blood of a patient in the last stages of

350 Flint, Jr., New Excretory Function of the Liver. [Oct.

cirrhosis of the liver, accompanied with jaundice, and compare it with an
examination of the blood of a patient suffering from simple icterus. Both
of these patients had decoloration of the feces ; but in the first, the icterus
was a grave symptom, accompanying the last stages of the disorganization
of the liver ; while in the latter, it was simply dependent on duodenitis, the
prognosis was favourable, and verified by the result. As icterus accompa-
nying jaundice is of very infrequent occurrence, I deemed myself very fortu-
nate in having an opportunity of comparing the two cases.

Case I. Jaundice dependent on obstruction from duodenitis. — Mary
Bishop, set. 42, native of Ireland, widow, occupation servant, was admitted
into the BlackwelPs Island Hospital, June 12, 1862, with the following
symptoms : Slight febrile movement, with severe pain over the duodenum ;
the surface of the body was highly icterosed ; the stools were clay -coloured ;
urine high-coloured, but not examined for bile ; lungs and heart normal ;
appetite rather poor ; no ascites. The icterus had existed since about May
23, 1862. The patient was confined to the bed.

Dr. Flint, the attending physician, pronounced it a case of icterus depend-
ent on duodenitis.

Treatment. — Laxatives daily, with good diet and a moderate amount of
stimulus.

June 21. A small quantity of blood was drawn from the arm for exa-
mination, and June 28, the feces were collected for the same purpose.
June 27. The patient remains about the same.

July 11. All pain and tenderness over the duodenum have disappeared.
She has steadily improved since the last record. The stools have been
natural for several days. Though confined to the bed most of the time,
she is able to sit up two or three hours daily. The jaundice has been
gradually diminishing, and three or four days ago it had entirely disap-
peared, and is now absent.

July 12. Another specimen of the feces, which was of normal appear-
ance, was taken for examination.

Analysis of the Uoodfor cholesterine. — The blood was examined about
sixteen hours after it was taken from the arm. It had entirely separated
into serum and clot. The serum was of a bright yellow colour — more
markedly bilious than in the succeeding case. It was evaporated, pulver-
ized, and a quantitative analysis for cholesterine made, with the following
results : —

Quantity of blood 212.428 grains.

Quantity of cholesterine 0.108 "

Proportion of cliolesterine per 1,000 pts. of blood . 0.508 "

Case II. Jaundice with cirrhosis. — Ann Thompson, set. 39, native of
Ireland, occupation servant, was admitted into the BlackwelPs Island Hos-
pital June 16, 1862, and gave the following history : —

Three months ago she contracted a severe cold, which was accompanied
with swelling of the left hand and of both legs, continuing for eight or
nine weeks. At the end of that time, she noticed that the abdomen was
increasing in size. She was then very weak, the urine was scanty, bowels
regular up to the time when she entered the hospital. She denied having
been in the habit of drinking spirit, but acknowledged that she drank beer.

June 18. liie surface of the body was very much icterosed, the colour

1862.]

Flint, Jr., New Excretory Function of the Liver.

351

being very marked under the tongue and in the conjunctiva ; the abdomen
was full of fluid ; pulse 90, small and weak ; bowels loose, and the dejec-
tions clay -coloured ; the urine highly tinged with bile and copious ; appetite
very poor. She was tapped, and about eight quarts of clear, straw-coloured
serum were evacuated. The patient was confined to the bed.

Dr. Flint, the attending physician, diagnosticated cirrhosis.

The treatment consisted of sustaining measures, with stimulants, and the
tinct. ferri muriat.

June 21. A small quantity of blood was taken from the arm for exam-
ination, and June 23, a specimen of the feces was obtained for the same
purpose.

The patient died June 2T. There were no convulsions, and she was
sensible, though in a state of stupor, up to twenty minutes before the fatal
termination. The stupor existed three or four days before death. Two
days before, she complained of double vision. The icterus was excessive up
to the time of her death.

Autopsy. — The abdomen contained about twelve quarts of fluid. The
liver was examined; its weight was 3 lbs. 12 J oz. It was very light-
coloured, and had something of the "hob-nail" appearance ; presenting, in
short, the gross characters of cirrhosis. The gall-bladder was very much
contracted, and contained only about two drachms of bile. Microscopic
examination of the organ showed the liver-cells shrunken. The fibrous sub-
stance was increased in quantity, and there were present a large number of
rather angular globules of fat.

Analysis of the blood for cliolesterine. — The blood was examined about
sixteen hours after it was drawn. It had fully separated into serum and
clot, and the serum was of a greenish, yellow color. The whole, serum and
clot, was then evaporated, pulverized, and a quantitative analysis made for
cholesterine in the manner already indicated, with the following results : —

Quantity of blood ....... 50.776 grains.

Quantity of cholesterine ...... 0.093 "

Proportion of cholesterine per 1,000 pts". . . . 1.850 "

The following table gives a comparison of these results with those ob-
tained in the analyses of the three specimens of healthy blood from the
arm, which were examined at the same time, and all five specimens subjected
to identical processes.

Table of Quantity of Cliolesterine in Healthy Blood, Blood from Simple
Jaundice, and Jaundice with Cirrhosis.

Healthy Bloob.

Cholesterine
per 1,000 pts.
Male, set. 35 . . . 0.445
" " 22 ... 0.658
" " 24 . . . 0.751

Blood of Jaundice.

Cholesterine
per 1,000 pts.

Case I. Simple Jaundice . 0.508
" II. Jaundice with Cir-
rhosis . . . 1.850

Case I. Simple Jaundice. Percentage of increase over minimum

of healthy blood . . 14.157

Decrease below maximum . 32.357

Case II. Jaundice with Cirrhosis. Increase over minimum . 315.730

Increase over maximum . 146.338

352 Flint, Jr., New Excretory Function of the Liver. [Oct.

The results of the examination of the blood in these cases of disease are
very striking and instructive. We have already seen that the variations in
health are very considerable. In the three analyses here noted, the maxi-
mum was 0.751, and the minimum 0.445 pts. per 1,000. The conditions
which regulate this variation it has not yet been possible to study ; but we
know enough with regard to it to see that in the examination of blood in dis-
ease, the cholesterine must mount considerably above the maximum, or fall
much below the minimum, to be considered beyond the limits of health. But
in the second specimen of jaundiced blood, the variation from the limits of
health is so considerable as to enable us to draw very important physiolo-
gical and pathological conclusions.

In the first place, what is the bearing of these observations on the physi-
ology of cholesterine ? As before remarked, no one has been able to remove
the liver from a living animal, and notice the effect upon the quantity of
cholesterine in the blood.* This experiment, if it were possible,- and if it
showed that the cholesterine increased in quantity, and killed the animal, would
be positive proof that it was an excrementitious substance, and that it was
removed by the liver. But while the experimental physiologist contributes
much to the information of the pathologist by artificially producing abnor-
mal conditions, pathology furnishes a multitude of useful experiments of
Nature, if we may so term them, which are invaluable to the physiologist.
In the present instance, cases of disease of the liver present a condition
w^hich we are not at present able to imitate by experiments on the lower
animals. Disorganizing disease of the liver must interfere with its excretory
function, as Bright's disease does with the elimination of urea ; and if cho-
lesterine be an excrementitious substance to be removed by the liver, when
the liver is seriously affected with structural disease, we will have an accu-
mulation of it in the blood. This, if fully established, is positive py^oof
of the character of cholesterine and the function of the liver connected
loith. its eliminaiion.

What do we learn then by a comparison of the blood in Case II. of jaun-
dice dependent on cirrhosis, with healthy blood and a study of the history
of the case ?

The cholesterine, in this instance, is enormously increased in quantity,
815. If 30 per cent, over the minimum, and 146.338 per cent, over the maxi-
mum. The case, as far as symptoms are concerned, was of a very grave
character. The patient not only suffered from an accumulation of fluid,
but there was evidently a poison in the system. The patient died after

1 Miiller, Kunde, and Moleschott, have succeeded in extirpating the liver from
frogs, and keeping them alive for two or three days — Moleschott preserving them
for several weeks. These observations were made with reference to the accumu-
lation of the biliary salts, and of the bile pigment in the blood, their attention not
having been directed to cholesterine. A series of experiments on frogs was com-
menced by the writer, but they promised to be so prolonged that they were deferred.

1862.] Flint, Jr., New Excretory Function of the Liver. 853

three or four days of stupor, and, on post-mortem examination, the liver
was found disorganized. There was a deficient secretion of bile, and had
been for a long time, for the gall-bladder was very much contracted, and
the stools were clay-coloured. In short the patient died of cholesteremia ;
and the fact that this condition can exist is a proof of the excrementitious
function of the cholesterine, as uremia, as a toxemic condition, presup-
poses that urea is an excrement.

Physiologically this case fulfils the essential condition of excrementitious
substances ; namely, accumulation in the blood when the eliminating func-
tions of the excretory organs are interfered with. The liver became so
disorganized that its functions were seriously embarrassed, and the quantity
of cholesterine in the blood increased to an enormous extent.

The pathological deductions from the facts which have been elicited by
the examination of the blood in these cases seem to me of great importance.
The literature of diseases connected with disorders of the liver is full of
theories, more or less plausible, to explain certain conditions which have long
been established by clinical observation. We have cases of simple jaundice
which are not dangerous to life, and sometimes, though the icterus be ex-
cessive, run a certain course without even interfering with the ordinary
avocations of the patient. Again, we have jaundice which is invariably
fatal. That disease described by Frerichs under the name of acute atrophy
of the liver, and called by some acute jaundice, is one of the most serious
diseases of which we have any knowledge. The existence of this great
difference has led clinical observers to attribute the mild cases to simple
resorption of the colouring matter of the bile, and the severe cases to a
retention or resorption of some of its more important constituents ; especi-
ally as it has also been observed that the symptoms which characterize the
latter condition occasionally occur in structural diseases of the liver without
any discoloration of the skin. But the pathology of this disease has been
entirely unknown. It has been thought that in such cases some of the
elements of the bile should exist in the blood. Frerichs says: "In the
same way that urea accumulates in large quantity in the blood in granular
degeneration of the kidneys, so ought the biliary acids and bile-pigment to
accumulate in the blood in cases of granular liver. Kepeated observations
have proved that this is not the case."^ Experiments on animals have
been followed with like results. The frogs that were kept alive by Mole-
schott for weeks after the removal of the liver did not present a trace of
any of the biliary salts or pigment in any part of the system, showing that
these matters are manufactured in the liver. This obscurity, which leads
to all sorts of theories with regard to liver pathology, must exist as long
as our knowledge of the physiology of the bile is so indefinite. If ob-

^ A Clinical Treatise on Diseases of the Liver, by Dr. Fried. Tlieod. Frerichs,
Prof, of Clinical Medicine, &c., Berlin. Translated by Charles Murchisou, M. D.
The New Sydenham Society, London, 1860, vol. i. p. 83.
No. LXXXYIIL— Oct. 1862. 23

854 Flint, Jr., New Excretory Function of the Liver. [Oct.

servers had looked for cholesterine — a substance which pre-exists in the
blood and is separated by the liver — instead of the biliary salts — which do
not pre-exist in the blood, are manufactured in the liver, as these experi-
ments tended to show, and are peculiar to the bile — they would have met
with different results. The very fact that the biliary salts are peculiar to
the bile, and found in no other fluid, should have led them to disregard this
substance in their analyses of the blood, because this stamps it as a secre-
tion and distinguishes it from the excretions ; they should have looked for
some substance which exists in the blood as well as the bile, an indispen-
sable condition of an excretion, and this substance is the cholesterine.

Understanding, as we now do, the physiological relations of the choles-
terine, we may divide jaundice into two varieties : simple Icterus, or yel-
lowness, and* a condition which I have called Cholesteremia. We may
have, also, the latter condition unaccompanied by discoloration of the skin.

Simple icterus. — In simple icterus we have a resorption of the colour-
ing matter from the biliary passages. As it has been proven that the
colouring matter of the bile appears first in the liver, when it exists in the
blood, it is not due to accumulation, but to resorption. In these cases the
resorption is generally dependent on obstruction from some cause, by
means of which the bile is confined. The patient suffers only from the
disease which causes the obstruction, and from th(? derangement of diges-
tion which is due to the absence of bile in the intestinal canal. In those
cases, in which we have no organic lesion of the liver, there is no danger
of absorption of the cholesterine. We have a condition which is analo-
gous to retention of urine. The patient sufi'ers simply from retention of bile
in the excretory passages, and cholesteremia is no more to be expected from
obstruction of the bile duct without structural changes of the liver, than
uremia is to be looked for in vesical retention of urine without organic
change in the kidneys. Excrements are not reabsorbed, though they may
be retained in the blood.

The quantity of cholesterine in the blood is not necessarily increased in
simple icterus, for the liver is still performing its function of eliminating
it, and when once separated from the blood it is not taken up again. The
analysis of the blood in Case I. indicated a proportion of 0.508 parts per
1,000, which is within the limits of health ; a little below the mean, pro-
bably on account of the somewhat enfeebled condition of the patient.

The feces may or may not be decolorized, this depending on the extent
of the obstruction to the passage of bile into the intestine. The obstruc-
tion to the flow of bile is frequently removed before the system has time
to remove the coloration of the skin, and the feces become normal while
the patient is icterosed. In some instances there is no change in the appear-
ance of the dejections during the course of the disease. When the dejec-
tions are' entirely decolorized there is an absence of the stercorine, into
which the cholesterine is transformed before it is discharged, with an ab-

1862.] Flint, Jr., New Excretory Function of tlie Liver. 355

normal quantity of fat which has passed through undigested.^ This ele-
ment reappears in the feces when the flow of bile is re-estabhshed and they
assume their normal colour.

The two following analyses were made of the feces in Case I. ; one, when
they were entirely decolorized, and the patient was very much icterosed,
and the other, when she had recovered, and the dejections had assumed their
natural appearance.

Feces of Case I. Jaundice dependent on duodenitis. First analysis. —
The feces were clay -coloured, and apparently destitute of bile. They weighed
941.4 grains. They were evaporated to dryness without difficulty, pulver-
ized, digested with fgiij of ether for twenty hours, filtered through animal
charcoal, evaporated and extracted with hot alcohol. The fatty residue
after evaporation of the alcohol was very abundant.

The residue was then treated with a solution of caustic potash and ex-
posed to a gentle heat. In fifteen minutes it became entirely saponified,
forming a clear homogeneous soap with no residue, showing the entire ab-
sence of stercorine. The soap was boiled down and moulded into a cake,
which I preserved and which weighs 34 grains. The following are the
results of the examination :—

Quantity of feces 941.4 grains.

fat 39.124 "

Percentage of fat 4.144

No stercorine or other Jion-saponifiable fats.

Feces nineteeji days after. Second analysis. — At that time the patient
had entirely recovered from the jaundice, and the feces had regained their
natural appearance. A small specimen was taken for chemical examina-
tion, which was done, employing the process already described for the ex-
traction of stercorine, with the following results : —

Quantity of feces 503. grains.

" stercorine . . . . . . . 0.340 "

Cholesteremia with icterus. — In jaundice complicated with blood poison-
ing we have a very different state of things as regards gravity of symptoms
and prognosis. This occurs in acute jaundice, or when it accompanies, and
is dependent upon, structural change in the liver, as the jaundice of cir-
rhosis. The difference in the pathology of these cases, compared with
those of simple icterus, has long been recognized; but, as before remarked,
analysis of the blood has failed to throw any light on the subject, because
chemists directed their attention exclusively to the biliary salts. Frerichs
says : —

" I have myself repeatedly examined jaundiced blood, which has been obtained
by venesection, or still more frequently, from the heart or venae cavse of the
dead body, for the biliary acids, and their immediate derivatives ; and more re-
cently I have had it examined by my assistant. Dr. Valentin, but always with
negative results. No substance could be found in the alcohohc extract of the

• TTiis fact, wMch lias often been remarked, seems to indicate that the bile is
actively concerned in the digestion of the fats. I have noticed that dogs with
biliary fistulce, though with a ravenous appetite, refuse to eat fat meat. This dis-
inclination to eat fat has been noticed in cases of jaundice with decoloration of
the feces.

356 Flint, Jr., Xew Excretory Function of the Liver. [Oct.

blood wMch yielded any indication, by Pettenkoffer's test for the biliary acids,
whether this alcoholic extract was treated directly with sulphuric acid and sugar,
or whether, in order to get rid of foreign substances, a watery extract of it was
first prepared. This coincides with the experience of most of the older ob-
servers."'

In cases of blood poisoning by retention and accumulation of elements
of the bile in the blood, we have, as the important pathological condition,
the great increase in the quantity of cholesterine. The fact of accumula-
tion of this substance in the blood in certain cases of icterus, has been no-
ticed by Becquerel and Kodier; but they do not connect it with structural
change in the liver, and do not explain its physiological or pathological
importance. The fact of its accumulation in the blood is strong evidence
of its excrementitious function, but this does not appear to have attracted
the attention of the observers just mentioned. The following is one of the
cases in which increase of the cholesterine was observed by them, the only
one in which they allude to its significance, and here merely to state their
inability to explain it : —

"The second case is nearly similar, excepting the phlegmasia, which did not
exist. It relates to a boy. nineteen years of age, a limonadier, affected for some
time with a bilious diarrhoea, with fever, and icterus, recently developed and
very marked. There existed in the blood of this patient a slight diminution of
the globules (136); albumen in normal quantity (71.4); likewise fibrin (2.3);
fatty matter sufficiently abundant; seroline in an imponderable quantity ; cho-
lesterine excessively abundant (0.798) ; soaps abundant (2,032). To what cause
must we attribute this great quantity of cholesterine ? How and wliy is it con-
centrated in the blood in s])ite of the biliary flux ? This is what it is difficult
to decide.''^

The acquaintance we now have with the physiology of cholesterine re-
moves the difficulty in the explanation of this fact. In Case II. we had the
rare complication of jaundice with cirrhosis, the symptoms evidently point-
ing to poisoning by retention of some noxious element in the blood. Ex-
amination of the blood in this case showed that the cholesterine existed in
the proportion of 1.850 parts per 1,000; the minimum of healthy blood
being 0.445 and the maximum 0.751 parts. Taking this case as an exam-
ple, we have cholesteremia with jaundice presenting symptoms which cha-
racterize the retention of bile in the blood, which are already well known,
and were established long before we were able to say what element was
retained. Cases in which jaundice exists with cholesteremia are so differ-
ent from cases of ordinary jaundice that there is no difficulty in making the
discrimination by symptoms. When jaundice exists with cirrhosis, it is
probable that we always have cholesteremia. In acute jaundice the symp-
toms, especially those referable to the nervous system, are so marked that
the gravity of the case is easily recognized. I have no doubt but in such
cases the cholesterine is immensely increased in the blood, though on ac-
count of their rarity I have not had an opportunity of determining this by

1 Frerichs, op. cit., page 95.

2 Translated from Becquerel and Rodier, op. cit., page 210. The Italics are my
own.

1862.] Flint, Jr., New Excretory Function of the Liver. 3 St

analysis. Icterus with cholesteremia and simple icterus are as distinct from
each other as possible. The only feature they have in common is the dis-
coloration of the skin. The simple icterus, which is comparatively harm-
less, is not liable to run into the more severe variety, which cannot occur
without structural change in the liver ; while the grave variety occurs when
we have evidence of organic lesion of the liver, or presents symptoms from
*the first which indicate its serious character. The one has no more con-
stitutional danger than exists in a simple case of spasmodic retention of
urine, while the other has characters as grave as those which accompany
uremic poisoning from disorganization of the kidney.

In these cases the feces may show a very marked deficiency of bile, but
this is due to the deficient, but not arrested, secretion of this fluid, while
the clay-coloured stools in simple icterus are dependent on the want of dis-
charge of the bile into the intestine. While in the latter instance, as in
Case I., we would expect to find an absence of stercorine in the dejections, in
the former we would expect to find it, though in greatly diminished quan-
tity. Further examination of the feces in cases of structural disease of the
liver will be of immense advantage as indicating, by the quantity of sterco-
rine found, the extent to which the eliminative function of the liver is inter-
fered with.

The following analysis was made of the feces in Case II. of jaundice de-
pendent on cirrhosis.

Feces of Case II. Jaundice dependent on cirrhosis. — The feces were
clay -coloured, though it was not quite as marked as in the Case I. of
simple jaundice.

The specimen was evaporated with great difficulty. It came down to a
black glutinous mass which could not be pulverized. It was treated twice
with alcohol, the alcohol evaporated, and once with ether. After the
ether had evaporated it was pulverized and analyzed for stercorine, with the
following results : —

Quantity of feces 272.1 grains.

Stercorine 0.077 "

In this analysis we have a very great diminution of the stercorine in the

feces, the normal quantity in the daily passages, according to the single

examination I have made, being 10.417 grains. The specimen was the

ordinary amount passed daily. It showed that the cholesterine was still

eliminated, though not with sufficient activity to prevent its accumulation

in the system. This was further evidenced by the post-mortem examination,

when the gall-bladder was found contracted, but containing a small quantity

of bile.

Examination of the blood and feces of the patient suffering under cho-
lesteremia with jaundice, thus leads to the following conclusions : —

1. The cholesterine is enormously increased injhe blood, showing that
the structural change in the liver has interfered luith its removal from
that fluid.

358 Flint, Jr., Xew Excretory Function of the Liver. [Oct.

2. The stercorine is cori^espondingly diminished in the feces, showing
that the cholesterine is not discharged in normal quantity into the alimen-
tary canal.

Cholesteremia without icterus. — In a practical point of view, this con-
dition becomes one wliich it is very important to be able to recognize ; bnt
it is here that we feel most the necessity of more extended investigations than
it has been possible to make. I have been enabled only to open the subject
by the analysis of one or two specimens of blood taken from patients who
had organic change in the liver, but no jaundice. One of the most familiar
of these affections of the liver consists in those changes of structure
which are included in the term cirrhosis. It is very unusual to find this
associated with jaundice, and we have already seen how serious this symp-
tom is. Frerichs describes a condition which he calls acholia, denoting
suppression of the functions of the liver. This is the same condition which
I have called cholesteremia, which expresses the element of the bile which
produces the toxic effects, the action of which was unknown to Frerichs,
while the term acholia expresses retention of bile without giving us any
idea of the active morbific agent. Further investigation will, undoubtedly,
establish more fully what the analyses I have made thus far seem to show,
namely, that in what Frerichs calls acholia without jaundice, we have
the cholesteremic condition we have seen to exist in acholia with jaundice.
The following quotation from Frerichs' admirable treatise on the liver, gives
an idea of one of the conditions in which we have acholia (or cholesteremia)
with or without jaundice.^

" Cases have repeatedly occurred to me, in which individuals who for a long
period have suffered from cirrhosis of the liver, have suddenly presented a series
of symptoms which are foreign to that disease. They have become unconscious,
and have been afterwards seized with noisy delirium, from which they passed to
deep coma, and in this state have died. In one case there was spasmodic con-
traction of the muscles of the left side of the face. In most cases, slight
jaundice made its appearance at the same time, and in one instance there were
petechise. Upon post-mortem examination, not the slightest lesion could be
detected in the brain, neither were there indications of any acute disease which
could account for the derangement of the cerebral functions. The Uver, in all
cases, presented cirrhotic degeneration in a marked degree, and the glandular
cells were for the most part loaded with fat; large quantities of leucine separating
from it ; the bile ducts contaiued only a small quantity of pale bile."

In certain cases of organic lesion of the liver, and probably in all cases
accompanied by the grave symptoms mentioned by Frerichs, we have cho-
lesteremia ; but this character does not exist in all cases where the liver is
affected, any more than uremia exists in all cases of structural disease of
the kidney. Nature not only provides organs which are sufficient for the
removal of effete matters from the blood, but provides for conditions in
which the function of these organs may be partly interrupted, and yet the
excretion go on, a pari taking on the function of the whole. One of the
kidneys may be removed, and yet the other, increased in size it is true, is

' . 1 Frerichs, op. cit., page 241.

1862.] Flint, Jr., ^^ew Excretory Function of the Liver.

359

capable of performing the function of both. The kidneys may be partially
disorganized, and yet the sound portion be sufficient for the depurative func-
tion, and urea will not accumulate in the blood. So it is with the liver. We
see patients with partial disintegration of this organ, as in some cases of
cirrhosis, suffering apparently but little inconvenience from the disease,
and presenting none of the symptoms of cholesteremia. But when the
'liver is extensively aiiected, so much so that it cannot separate the choles-
terine effectually from the blood, we have the condition of cholesteremia.
I have made an analysis of the blood of two patients affected with cirrho-
sis, who presented this contrast as regards the symptoms of cholesteremia.
In one of them. Case III., there was considerable constitutional disturb-
ance ; and in the other, Case lY., the patient was about, and suffered no
great inconvenience, though he had been tapped for ascites about thirty
times.

Case III. Cirrhosis with ascites, and consideroMe affection of the
general health. — Mary Perkins, set. 23, native of Ireland, prostitute, has been
a spirit-drinker for about seven years, about the first of May, 1862, noticed
an enlargement of the abdomen, which was accompanied with pain over
the region of the liver, when she took to the bed. She states that at that
time the stools were dark green. Fluid continued to accumulate in the
abdomen, and was drawn off in the hospital (Blackwell's Island), June 25.
About six quarts of a clear, straw-coloured serum were removed, but a
little was left in the abdomen, as the patient was very weak. The patient
improved after the removal of the fluid, which did not reaccumulate in any
considerable quantity. The liver was found diminished in size, and from
this and other circumstances, the diagnosis was cirrhosis.

June 28. A specimen of blood was taken from the arm for examination.
She left the hospital July 6, and was confined to the bed till within a few
days of her discharge.

Analysis of the Mood for cholesterine. — The blood presented nothing
peculiar in its appearance. A quantitative analysis was made for choleste-
rine, with the following results: —

Quantity of blood 117.193 grains.

" " cholesterine 0.108 "

Proportion of cholesterine per 1,000 parts of blood . 0.922 "

Case IY. Cirrhosis with ascites, and slight constitutional disturhance.
— Thomas Hughes, set. about 33, brewer, presented himself at the Long-
Island College Hospital, July 1, 1862, with Dr. Dugan, of Williamsburg.
He confesses to have been-in the habit of drinking more or less spirit daily
for the past ten years. The abdomen began to swell about eighteen months
ago. The ascites was preceded by h^matemesis, when he vomited an abun-
dance of black, clotted blood. The belly immediately began to swell, and
enlarged rapidly. He took hydragogues under the direction of a physician,
and the dropsy disappeared, but returned whenever the medicines were dis-
continued. (Edema of the lower limbs occurred soon after the ascites com-
menced. He has had recurrence of hagmatemesis twice since the first
attack.

He was first tapped two or three mouths after the affection occurred, and
has been tapped about thirty times since. Was tapped last on the 2Tth

360

Flint, Jr., New Excretory Function of the Liver.

[Oct.

ult. He is tapped and goes out the next day. He tJiinks nothing of it,
and is always for the time relieved. He has continued to drink beer daily
and some spirit. After tapi3ing his appetite is good, and food occasions
no inconvenience. When he is full, food occasions a distressing distension,
so that he does not eat freely.

Urine is scanty when the abdomen is full, and free, after tapping.

There is no pain in the belly, or elsewhere. He is about all day, but is
not engaged in business. He says he is not very feeble. He presents a
notably anaemic aspect.

The abdomen is now moderately full (July 1.) Superficial veins of ab-
domen much enlarged. Heart appears not enlarged ; a feeble systolic mur-
mur over the body of the organ.

Several months before the ascites began, he got into a fracas, and was
beaten badly. He was not laid up, but says he did not feel well afterward,
and is disposed to attribute his disease thereto.

Advised to continue to tap when the abdomen refills, with tonics, hygi-
enic measures, and abstinence from spirit, continuing the use of ale mode-
rately. (Private records of Dr. Flint.)

July 1. A specimen of blood was taken from the arm for examination.

Analysis of the blood for cholesterine. — The blood was treated in the
usual way, and a quantitative analysis made for cholesterine, with the fol-
lowing results : —

Quantity of blood . . . . . , . 251.567 grains.

" " cholesterine 0.062 "

Proportion of cholesterine to 1,000 parts of blood . 0.246 "

The following table shows the comparative quantity of cholesterine in
these specimens, and in the three specimens of healthy blood.

Healthy Blood.

Cholesterine
per 1,000 pts.
Male, ffit. 35 . . ^ . 0.445
" " 22 . . ' . 0.658
" " 24 . . . 0.751
Case III. Cirrhosis (severe). Percentage of increase in cholesterine

over miuimnm of healthy blood . 107.190
Ditto over maximum . . . 22.769
Case IV. Cirrhosis (mild). Percentage of decrease in cholesterine

below minimum of healthy blood . 42.469

These two cases present a very striking contrast ; and the chemical exa-
mination of the blood has shown as marked a difference in the quantity of
cholesterine, as in the gravity of the attendant symptoms. It teaches, how-
ever, an important lesson. We do not always have an accumulation of
cholesterine in the blood when the structure of the liver is altered; it
being requisite that this alteration should involve enough of the organ to
interfere with the elimination of this substance. The quantity may even
fall below the natural standard, in a patient who is rendered anemic by
the consequences of a cirrhosis, which is not sufficient to induce choleste-
remia. The process of nutrition being thereby diminished in activity, the
production of this substance, by destructive assimilation, is necessarily dimi-

Blood of Ciekhosis.

Cholesterine
per 1,000 pts.

Case III. Cirrhosis (severe) 0.922
Case IV. Cirrhosis (mild) . 0.246

1862.] Flint, Jr., New Excretory Function of the Liver. 361

nislied. The cholesteremia may be slight and transient ; for the causes
which produce it may be, to a certain extent, temporary. In Case III. we
have the patient confined to the bed, suffering acute pain over the region
of the liver, in all probability due to a slight degree of inflammation. This
interfered with the excretion of cholesterine, and we find its proportion in
the blood increased to 22.169 percent, over the maximum, and lOt.190
over the minimum.^ As the patient was somewhat enfeebled by syphilis
before the symptoms of disease of the liver made their appearance, it is
probable that the quantity of cholesterine in the blood did not mount up
to the highest standard in health. At all events, there was a notable
increase even over the maximum quantity. Case lY. is not less instruc-
tive. Here we have a patient who has had cirrhosis of the liver, with
ascites, for eighteen months, and has been tapped upwards of thirty times.
He apparently has suffered from nothing more than the mechanical effects
of the liquid, which has interfered at times with digestion, and rendered
him anaemic. He is tapped, and immediately relieved, going out the next
day. We do not seem to have any interference with the functions of the
liver, as far as the symptoms are concerned, other than the mechanical
obstruction to the circulation, and the case, in its symptoms, resembles one
of those cases of ovarian dropsy where we have the patient carrying about
an immense quantity of water, but suffering only from this circumstance,
and relieved temporarily when the water is removed. Considering the state
of the patient, we should not be surprised to find the cholesterine of the
blood not increased, but diminished in quantity ; and we may, I think,
come to the conclusion from the symptoms, as well as the analysis of the
blood, that though the liver was affected sufficiently to produce obstruction
of the circulation, there was not sufficient disease to produce cholesteremia.

It is evident that much more extended observations are necessary in order
to establish the clinical relations of cholesteremia without jaundice ; but
the case of Mary Perkins shows that this condition does exist, while
the case of Thomas Hughes shows that it does not follow structural change
in the liver, unless the lesion be extensive. The fact that we may have
poisoning of the blood by the retention of a biliary matter, without disco-
loration of the skin, is exceeding important ; and of this there seems to me to
be no doubt. When we have a patient who has structural disease of the
liver, and presents symptoms of blood-poisoning, he is suffering under cho-
lesteremia, though there be no icterus. The cholesteremia may vary in
degree from the mildness which characterized Case III., in which it was,
perhaps, temporary,^ to the grave condition mentioned by Frerichs, charac-
terized by noisy delirium and coma, and announcing a speedy fatal termi-
nation. When we add to these conditions the cases of what is ordinarily

^ Unfortunately the character of the stools was not noted.

2 The patient having gone out of the hospital, it was impossible to settle this
point experimentally.

362

Flii^^t, Jr., New Excretory Function of the Liver. [Oct.

called biliousness, attended with drowsiness, an indefinite feeling of malaise,
constipation, etc. (and all this relieved by a simple mercurial purge, which
is said to promote the secretion of the liver), cannot we hope that some
light will be shed on their pathology by a knowledge that there is a con-
dition called cholesteremia ? As yet this is but speculation ; but the dis-
covery of the important function of cholesterine opens an almost boundless
field of inquiry in this direction ; and ere long the physician may talk of
"biliousness," and "liver complaint," with some definite ideas of their
pathology.

The following table gives the results of the quantitative analyses for
cholesterine, which have been referred to in this article.

Table of Quantitative Analyses for Cholesterine.

Quantity

Cliolesterine

examined.

per 1,000 pts.

grains

Human blood from the arm. Healthy male aet. 35 .

" «t. 22 .

A AAK
U.'i'iO

lO / .O'dtD

U.OOo

(f i( u

" " £et. 24 .

lUZ.ooU

V. IDl

u u a

Simple jaundice,

910/1 OQ

U.DUo

a a ii

Cholesteremia with jaundice

50.776

1.850

il il li

Cirrhosis (grave).

117.193

0.922

il 11 11

(mild),

25L567

o!246

il 11 11

Hemiplegia —

Case I. Paralyzed side .

55.458

Sound side

128.407

0.481

Case II. Paralyzed side .

18.381

Sound side

66.396

0.808

Case III. Paralyzed side

21.824

Sound side

52.261

0.579

Blood from carotid

179.462

0.774

" " internal jugular

- Dog experiment

134.780

0.801

" " femoral vein

133.886

0.806

" " carotid ^
" " internal jugular j

> Dog experiment | '

140.847
97.811

0.768
0.947

" " carotid

143.625

0.967

" " internal jugular

^ Dog experiment.

29.956

1.545

" " femoral vein

45.035

1.028

" " carotid

159.537

1.257

" " portal vein

- Dog experiment

168.257

1.009

" " hepatic vein

79.848

0.964

Human brain (subject killec

. instantly)

159.753

7.729

" (Case IL, killed instantly)

150.881

11.456

Human bile (specimen from Case II.) ....

224.588

0.618

Crystalline lens (4 lenses from the ox) ....

135.020

0.907

Meconium

170.541

6.245

Conclusions. — The observations contained in the preceding article seem
to the writer to justify the following conclusions : —

1. Cholesterine exists in the bile, the blood, the nervous matter, the
crystalline lens, and the meconium, but does not exist in the feces in ordi-
nary conditions. The quantity of cholesterine in the blood of the arm is
from five to eight times more than the ordinary estimate.

1862.] Flint, Jr., "New Excretory Function of the Liver. 363

2. Cbolesterine is formed, in great part if not entirely, in the substance of
the nervous matter, where it exists in great abundance, from which it is
taken up by the blood, and constitutes one of the most important of the effete
or excrementitious products of the body. Its formation is constant, it
always existing in the nervous matter and the circulating fluid.

3. Cholesterine is separated from the blood by the liver, appears as a
constant element of the bile, and is discharged into the alimentary canal.
The history of this substance, in the circulating fluid and in the bile, mark
it as a product destined to be gotten rid of by the system, or an excretion.
It pre-exists in the blood, subserves no useful purpose in the economy, is
separated by the liver and not manufactured there, and, if this separation
be interfered with, accumulates in the system, producing blood-poisoning.

4. The bile has two separate and distinct functions dependent on the
presence of two elements of an entirely different character. It has a func-
tion connected with nutrition. This is dependent on the presence of the
glyco-cholate and tauro-cholate of soda, which do not pre-exist in the blood,
subserve a useful purpose in the economy, and are not discharged from it,
are manufactured in the liver and peculiar to the bile, do not accumulate in
the blood when the function of the liver is interfered with, and are, in short,
products of secretion. But it has another function connected with depura-
tion, which is dependent on the presence of the cholesterine, which is an
excretion. The flow of the bile is remittent, being much increased during
the digestive act, but produced during the intervals of digestion, for the
purpose of separating the cholesterine from the blood which is constantly
receiving it.

5. The ordinary normal feces do not contain cholesterine, but contain
stercorine (formerly called seroline, from its being supposed to exist only
in the serum of the blood), produced by a transformation of the cholesterine
of the bile during the digestive act.

6. The change of cholesterine into stercorine does not take place when
digestion is arrested, or before this process commences ; consequently, ster-
corine is not found in the meconium, or in the feces of hibernating animals
during their torpid condition. These matters contain cholesterine in large
abundance, which also sometimes appears in the feces of animals after a
prolonged fast. Stercorine is the form in which cholesterine is discharged
from the body.

Y. The difference between the two varieties of jaundice with which we
are familiar, the one characterized only by yellowness of the skin, and
comparatively innocuous, while the other is attended with very grave symp-
toms, and is almost invariably fatal, is dependent upon the obstruction of
the bile in the one case, and its suppression in the other. In the first in-
stance, the bile is confined in the excretory passages, and its colouring
matter is absorbed, while in the other, the cholesterine is retained in the
blood, and acts as a poison.

364 Flint, Jr., New Excretory Function of the Liver. [Oct.

8. There is a condition of the blood dependent upon the accumulation
of cholesterine which I have called Cholesteremia. This only occurs when
there is structural change in the liver, which incapacitates it from perform-
ing its excretory functions. It is characterized by symptoms of a grave
character, referable to the brain, and dependent upon the poisonous effects
of the retained cholesterine on this organ. It occurs with or without
jaundice.

9. Cholesteremia does not occur in every instance of structural disease of
the liver. Enough of the liver must be destroyed to prevent the due elimi-
nation of the cholesterine. In cases in which the organ is but moderately
affected, the sound portion is capable of performing the eliminative function
of the whole.

10. In cases of simple jaundice, when the feces are decolorized and the
bile is entirely shut off from the intestine, stercorine is not found in the
evacuations ; but in cases of jaundice with cholesteremia, the stercorine may
be found, though always very much diminished in quantity, showing that
there is an insufficiency in the separation of the cholesterine from the blood,
though its excretion is not entirely suspended. After death, but a small
quantity of bile is found in the gall-bladder.

In concluding, I beg leave to express my acknowledgments to my
assistant, Mr. Henry E. Paine, of Providence, R. I., one of the residents of
the Bellevue Hospital, who has assisted me indefatigably in the analyses
and experiments which form the basis of this paper ; and to whose intelli-
gent aid I am greatly indebted for the amount of labour which I was ena-
bled to accomplish in a comparatively short time. This aid, with the
advantages of the great hospital at BlackwelPs Island, which was laid under
contribution for the pathological observations, enabled me to carry on a
portion of the analyses uninterruptedly for about two months.

EXPLANATION OF THE PLATES.

Fig. 1. — Cholesterine extracted from the meconium, inch objective.
YiG. 2. — Stercorine and fatty matters from the blood of the carotid artery.
y'2 inch objective.

ipia. 3. — Cholesterine and small broken crystals of stercorine from the same
specimen of blood from the carotid, examined eleven days after.
Nachet, No. 3 objective.

Fig. 4. — Cholesterine from the brain. ^ inch objective.

Fig. 5. — Cholesterine from the blood of the internal jugular, with a few needles

of stercorine. inch objective.
Fig. 6. — Cholesterine and stercorine from the same extract as Fig. 5, examined

the next day. ^ inch objective.
Fig. 7. — Cholesterine and stercorine from the blood of the vena cava. |- inch

objective.

Fig. 8. — Cholesterine from the blood of the portal vein. ^ inch objective.

1862.]

Bill, Xotes on Arrow Wounds.

365

Fig. 9. — Cholesterine from the blood of the hepatic artery. ^ inch objective.
Fig. 10. — Cholesterine and stercorine from the blood of the hepatic artery.
^ inch objective.

Fig. 11. — Fatty substances from the blood of the hepatic vein. iiich objective.

Fig. 12. — Cholesterine and stercorine from the same specimen, examined the
following day. ^ inch objective.

Fig. 13. — Cholesterine extracted from the bile. ^ inch objective.

Fig. 14. — Stercorine from the human feces. j% inch objective.

Fig. 15. — Stercorine from the same specimen, after it had been melted, placed
on a glass slide, covered with thin glass, and allowed to crystallize.
The crystallization was very slow, occupying some weeks. This
Fig. shows the splitting up of the borders and points of the crystals
with the globules referred to on page 340. The globules were of
variable siz^, and some of them were arranged in rows, which, with
an inferior glass, might have been mistaken for varicosities on the
needles. From their appearance in this specimen, after it had been
so thoroughly purified, I am inclined to change the opinion expressed
page 340, and regard them as composed of stercorine and not fatty
impurities. ^ inch objective.

Art. IL — Notes on Arroiv Wounds, By J. H. Bill, M. D., Assistant
Surgeon U. S. A. (With three woodcuts.)

The arrow is a weapon of the greatest antiquity. It is one with
which, in this country, at least, we are all familiar ; nevertheless, there is
nowhere now extant an account of the wounds produced by it sufficiently
accurate or definite to guide a surgeon in their treatment, or to give to
the medical antiquary a record of their history and appearance. Before
long these wounds will become of unfrequent occurrence, for our Indian
tribes are fast being exterminated. We propose, in the first place, as a
matter of historical interest, to state in this article what we know of arrow
wounds. The subject still presents much of practical interest to the sur-
geon, and must continue so to do, in a greater or less degree, for the future.
It will be some time before all our Indian tribes are "civilized off the face
of all creation," and many a soldier and settler has yet to pay the death
penalty for his courage or hardihood. Moreover, the bow and arrow is in
use among the Tscherkesses of the Russian army, for the purpose of picking
off sentinels without creating an alarm. ^ It is probable that a corps of
carefully selected bowmen would be found of great use in our' own army for
like purposes. Franklin has suggested the employment of arrows in battles,
to be shot from bows or fired from guns. Arrow wounds are, therefore, and
for some time likely to be, of practical interest.

^ Vide McClellan, Military Commission to Europe.

366

Bill, IN'otes on Arrow Wounds.

[Oct.

So mucli as an apology for the appearance of this article.

As is well known the arrow is the favourite weapon of all our Indian
tribes, and it is such because in skilful and desperate hands the wound which
it inflicts is attended with a fatality greater than that produced by any
other weapon — particularly when surgical assistance cannot be obtained.
The weapon is constructed not only to disable an antagonist, but also to
kill sooner or later its victim.

In order fully to appreciate the subject of arrow wounds, it will be neces-
sary to understand the mechanism and construction of the arrow itself. Let
us briefly explain this.

The arrow is composed of two parts, a shaft and a head. The shaft
varies in length from two to three feet. Usually it is made from a limb of
the dogwood tree. A limb of a quarter-inch diameter is taken, soaked
in water, the bark peeled off, and then cut into suitable lengths.

The straightening process is now commenced. The ends of the piece to
be straightened are squared off, and two small and flat strips of wood
placed transversely, as regards the long axis of the piece, and firmly lashed
one to each end of the latter, in the manner of a cross. One of these sticks
is held between the teeth, whilst the other is grasped by the hand. This
end is now twisted to and fro by rotating the slip grasped by the hand, after
the manner of a trephine. The fibres of the stick to be straightened after
a while assume a spiral twist at the same time the stick itself is found to
be straight. It often will require three days to straighten a single shaft.
A notch is now filed at one end for the bowstring, and a slit made in the
other to receive the straight quadrangular stem which comes off from the
base of the head. The head is made of soft hoop iron, filed into the form
of an isosceles triangle, and furnished with a stem to attach it to the shaft.
This stem is an inch long by one-eighth of an inch broad, and is of one
piece with the rest of the head. An arrow-head varies in length from half
an inch to two inches, and half an inch to three-quarters of an inch in
breadth at its base. No two arrows are alike. The stem at the base of
the arrow-head is pushed into the slit made for it in the shaft, and held
there by wrapping narrow ribbons of tendon spirally around the split sides
of the latter, thus clamping these together, and the stem itself closely in
their embrace. If it were not for these ribbons the head would be held
loosely. It is then this ribbon of tendon that gives solidity to the arrow,
and makes of a head and a shaft a perfect and a most dangerous weapon.
The tendon removed and the weapon falls to pieces.

Such being the mechanism of the arrow, we can readily understand the
danger peculiar to arrow wounds in general, a danger often seen in pistol-
ball wounds of the chest. Let us suppose a case to illustrate and explain
our meaning. An arrow is shot at a man at a distance of fifty yards. It
penetrates 'his abdomen, and without wounding an intestine or a great ves-
sel, lodges in the body of one of the vertebrae. The arrow is grasped by

1862.]

Bill, Notes on Arrow Wounds.

36Y

the shaft by some officious friend, and after a little tugging is pulled out.
We said the arrow is pulled out. This was a mistake ; it is the shaft only
of the arrow that is pulled out. The angular and jagged head has been
left buried in the bone to kill — for so it surely will — the victim. The ex-
planation of such mishaps is this : the ribbon of tendon which compressed
together the split sides of the end of the arrow, and so clamped the head
and the shaft together, had become wetted with the fluids effused in the
course of the wound. When wetted, it was, of course, lengthened, and, if
lengthened, loosened. It ceased longer to bind together the split sides of
the shaft ; this and the head were, consequently, very feebly united and
readily detached. Experience has abundantly shown, and none know the
fact better than the Indians themselves, that any arrow wound of chest or
abdomen, in which the arrow-head is detached from the shaft and lodged,
is mortal. From this we conclude that the danger peculiar to all arrow
wounds is, that the shaft becoming detached from the head of an implanted
arrow, leaves this so deeply imbedded in a bone that it cannot be luithdraiun,
and that, remaining, it kills. It is not possible with forceps to extract an
arrow-head so lodged (if lodged deeply), throwing aside the difficulty of
discovering and the danger of searching for it. The blades of forceps long
enough for this purpose (supposing the foreign body deeply lodged in the
chest) would bend too readily with the force required for the removal of
the missile. The greatest force is sometimes required for the extraction of
an arrow-head so lodged. We have seen an arrow shot at a distance of
one hundred yards, so deeply imbedded in an oak plank, that it required
great force, applied by strong tooth-forceps, to remove it. In the case of
a man shot in the shaft of the humerus by an arrow, it was only after using
both knees, applied to the ends of the bone as a counter-extending force,
and a stout pair of tooth-forceps, that we succeeded in removing the foreign
body. Another similar case will be mentioned hereafter. Asst. Surgeon
McKee had a case, also, in which considerable force was required to extract
an arrow-head lodged in the trochanter, and other instances illustrating the
difficulty sometimes encountered in the removal of arrow-heads lodged in
bone could readily be adduced.

We have dwelt thus at length upon the mechanism of the arrow because
we consider that upon a rightful understanding of the same must depend
an intelligent and a skilful treatment of the wound which it occasions. The
arrow-head removed by proper treatment, and we have an ordinary punc-
tured wound, such as a poniard or stiletto would make. The wounds in-
flicted by these last named weapons are dangerous and troublesome for this
reason. When such a weapon pierces any deep tissue, it must do so
through some other tissue possessed of a contractile or muscular power.
As soon as the weapon is withdrawn, this last named tissue contracts, and
thus draws the wound in itself upwards or downwards, interrupting the
continuity of the wound as a whole ; whence it happens that all such

368

Bill, 'Notes on Arrow Wounds.

[Oct.

wounds, the pus or eflfused liquids finding no outlet, are apt to be attended
with burrowing of matter and deep-seated abscess. This remark applies to
arrow wounds, although they partake of the nature of incised wounds, and,
therefore, oftener heal by first intention than do the punctured wounds of
the stiletto or bayonet, attended as these are with much bruising and tear-
ing of tissues. Arrow wounds are often complicated by profuse hemorrhage,
and for the same reason that in bayonet wounds abscesses form, through
inability of matter, to find a ready outlet, in arrow wounds heematomata
result. In fact, when arrow wounds suppurate, they generally do so
through disorganization of these collections of blood.

It is occasionally the practice of some of our Indian tribes to poison their
arrows. The plan pursued is this (on the testimony of a Moquis Indian.)
The liver of some animal is exposed, and a rattlesnake compelled to insert
his fang into it. The animal is at once killed, the liver removed, and
wrapped up in the skin and buried. After seven or eight days the bundle
is dug up, and the arrow-heads dipped in the pulpy and putrescent mass in-
closed, in the skin. After they are dry they are dipped in blood, again
dried, and preserved for use.

We have never witnessed this process, but have seen arrows said to have
been subjected to it. A horse, however, was shot on a late Nabajoe cam-
paign in the flank with an arrow. He swelled up enormously, evidently
suffered much pain, and died in the course of a night, certainly from the
effects of a poison, as the wound inflicted by the arrow was not mortal,
either from its seat or its severity. Strange to say such arrows are of in-
frequent use. Among some seventy-six cases of arrow wounds received
from Nabajoe, Apache, and Utah Indians, we have seen no case of poisoned
arrow wound in the human subject, nor have we heard of such a case, after
careful inquiry. Of course a wound of this nature, if it involves parts be-
yond the reach of knife or cautery, is fatal.

What parts of the body are oftenest wounded by the arrow, and what is
the relative fatality ? The following table of cases, falling principally
under our own observation, will show : —

HEAD.

CHEST.

ABDOMEN.

Brain

wounded.

Brain not
wounded.

Spinal Marro-R

Neck.

Lung
wounded.

Lung not
wounded.

' Heart.

Intestine
wounded.

Intestine not
wounded.

Upper Extremi

Total.

Number of cases saved
" " died

2
4

3
31

27
1

5
1

51
29

Total ....

1 One of these perished from a gunshot wound.

1862.]

Bill, Notes on Arrow Wounds.

BG9

The above table includes all the reliable cases of arrow wounds falling
under our notice.

On referring to it, it will be seen that the upper extremity is oftenest
wounded, next comes the abdomen, next the chest, next the lower extremity,
next the head, and, lastly, the neck. The reason that the upper extremity
is so often wounded, is that a person can see an arrow darting towards him,
and very naturally putting out his arm to ward it off, receives a wound
oftener in this member than in any other. Wounds of the abdomen are
oftenest fatal (more than three-fifths of the total deaths occurred from
wounds of abdomen), next come wounds of chest, wounds of head and
heart next, and wounds of spinal marrow, and upper and lower extremity
are last.

An expert bowman can easily discharge six arrows per minute, and a
man wounded with one is almost sure to receive several arrows. In the
above table, when a man was wounded in more places than one, the most
serious wound, or that which immediately caused his death, is recorded.
We have not seen more than one or two men wounded by a single arrow
only. In three of our soldiers shot by Nabajoes, we counted forty-two
arrow wounds ; this is an extreme case, as the manufacture of the arrow
costs the Indian too much labour and time to expend one unnecessarily. The
cause of death in the twenty-nine fatal cases may be thus summed up : —

-a

o .

Catjse of Death.

Immcdia
Hemorrlu

Pcritoniti

Compress
ol' brair

Wound ol
Heart.

Empyema

Tetanus.

I'uGumon

Total.

Niimber of cases

Keeping in view the real cause of dread in arrow wounds — to wit, the
lodging and fixation of the iron head in a bone — let us now proceed to
consider the subject from a more limited view, and investigate the arrow
wounds of each separate part of the body.

First, then, for the simplest case ; an arrow wound involving no parts
essential to life. Let us suppose a case.

-A man is shot by an arrow which passes through integuments and mus-
cles, and grazing the bone, makes its exit on the other side of a limb.
What appearance is presented after the accident ? We will find at the spot
where the arrow entered, a very small and narrow slit, surrounded by a
circular patch of bruised integument of a dusky-red colour. It is almost
impossible to say whether the slit was made by a pistol-ball or an arrow,
so closely does the entrance wound made by an arrow resemble that made
by a small ball. On the other side of the limb another slit, somewhat
larger than that above described, is seen, but not surrounded by the red
areola. This is the exit wound. What is the treatment ? Apply cold or
No. LXXXYIII— Oct. 1862. 24

Z10

Bill, Notes on Arrow Wounds.

[Oct.

evaporating lotions, place the limb at perfect rest, let the patient diet him-
self, and the chances are favourable of such a wound healing by first inten-
tion. At all events this is the indication. Ordinarily, such a wound will be
quite well in a week. If we fail in our efforts at healing by first intention,
and matter forms, bandages, compresses, and an early evacuation of the
collection is the treatment ; generally, the pus will find its way to the sur-
face by the wound. It is not considered necessary to illustrate further,
although numerous cases might be cited in support of what we say. In
such cases the rule for any other punctured and incised wound obtains. If
any artery is divided, follow Guthrie's rule, and tie the divided vessel in the
wound itself, securing both the cardiac and distal ends of the artery. We
have seen but one case of a large artery of a limb divided by an arrow, and
that case terminated fatally before we saw the man. He was a Mexican,
and was shot in the groin while on horseback. The arrow pierced the fe-
moral artery just below Poupart's ligament. The man lived twelve hours,
but was brought into the post dead. The possibility of the deep vessels of
a limb being pierced by an arrow, must be apparent to any one, and it is
as well to keep it always in mind, and be prepared to tie the vessel before a
diffused traumatic aneurism is formed, which would greatly increase both
the danger and difficulty of the operation. Suppose a nerve-trunk has
been partially divided, and all the unpleasant symptoms consequent on such
an accident ensue, what is to be done ?

In such a case we think a surgeon justifiable in enlarging the wound, and
completing the division of the nerve.

Private Martin, of the 3d Infantry, was shot in his right leg by an arrow
— the arrow passing out. I saw him shortly after the receipt of the injury.
The only thing remarkable was the agonizing pain, referable to the small
toes and outside of foot. I suspected a wound of the musculo-cutaneous
nerve, and decided to cut down upon it, and, if necessary, to divide it. This
I did, and found the nerve as I had diagnosed, wounded. I divided it, and
the pain ceased, numbness taking its place. The man did well, the wound
healed by granulation, and ultimately sensation was regained in the outside
of the foot. The man was sent to duty on the twenty-eighth day. Of
course, such a procedure will not be rashly undertaken on a large nerve-
trunk, nor in any case in which pain is absent.

If an arrow, instead of passing through a limb, strikes a bone, it will
lodge, and that, too, so deeply, that nothing but forcible traction and judi-
cious movement will extract it. The wound should be enlarged with a bis-
toury, as the shaft of an arrow is always so tightly grasped by the tissues
through which it passes, that a forceps cannot be introduced for its extrac-
tion. An incision an inch to two inches in length will suffice, but it must divide
to this extent all the tissues, through which the arrow has passed. After
this has been made, pass down a finger, and explore the parts ; ascertain
the position, seat, and depth of the arrow-head in the bone. Then guide
down upon the finger a pair of straight tooth forceps, and make these em-

1862.]

Bill, Notes on Arrow Wounds.

371

brace the arrow-head ; remove the finger gently, till the arrow shifts from
side to side, so as to loosen its seat in the bone. Firm traction being now
made on the head by the forceps, the extraction will be sufficiently easy.
Treat the wound as a simple arrow wound. Supposing that the shaft has
become detached from the head of the arrow before the patient is seen.
This is an unfortunate occurrence. Frequently we will fail in detecting the
arrow-head, and even if found, its extraction must be a matter of difficulty.
The wound should be enlarged, and the finger used for exploring, as in the
previous case. If the head is found, the forceps must be applied, the finger
disengaged from the wound, and the forceps firmly grasped. A gentle
rocking motion of the handles of the latter, such as a dentist uses to ex-
tract a tooth, will, if enough of the arrow-head projects out of the bone,
suffice to disengage it. If it is deeply buried, nothing but sheer brute force
will accomplish its extraction. The following is a case in point.

Private Bishop was shot in the head of the humerus with an arrow, and
the shaft having been plucked out, the iron head was left deeply imbedded
in the bone. The man was in great pain, synovia was flowing out of the
wound, and all motion was lost. I enlarged the wound, introduced my
finger, and so ascertained the position and depth of the arrow-head. It
was ^erj deeply implanted. I introduced forceps, seized it by its base, but
could obtain scarcely any ''purchase." I at last succeeded in grasping it
tightly, and bracing my knees against the patient's thorax, I applied all
the traction I could muster. Suddenly the arrow-head flew out of its seat,
and I would have fallen on the floor, had not the steward caught me. The
wound healed well. It was treated by evaporating lotions, and a rigor-
ously antiphlogistic diet for the patient. Motion in the joint was not lost,
though somewhat impaired.

I have already alluded to another case, in which I removed an arrow
from the shaft of the humerus by bracing the end of the humerus against
my knees, and then applying all my strength to the foreign body by means
of forceps.

There is yet one case of arrow wound of limb of which we must speak,
in which the he^d lodges in a bone, but with a curious modification. It is
this. The point of the arrow-head scrapes the bone near the edge of this
latter, and just as it does so, the muscles of the limb contract violently, and
bend the point of the weapon. The arrow passes on, and again the muscles
contract, and again the point is bent, and so on ; so that by the time the
progress of the arrow is arrested, its head is bent to resemble a fish-hook,
the point, however, being firmly implanted, and immovably bound down to
the bone by the periosteum and cartilaginous structures, which it has strip-
ped off from their attachments. Of course, the greater the traction applied
to an arrow-head so lodged, the more firmly will it be imbedded. In such
a case, the fioger carried down to the foreign body, gives us all the informa-
tion that is needed, and it is just because such cases as these are of rather
frequent occurrence, that the digital examination of arrow wounds should

3t2

Bill, Notes on Arrow Wounds.

[Oct.

always be practised, when possible. In such a case, the head of the arrow
having been seized by forceps, as usual we vibrate these from side to side,
but instead of pulling, we gently push, so as to disengage the point of the
head from any lodgment it may have made in the bone, and then by gentle
movements of a rotatory character, aided by the finger, the final removal
of the foreign body will not be difiicult. The finger should be kept on the
point of the bent arrow-head, in order to prevent entangling this in such
tissues as may be in the way.

We have seen two cases such as that above described, and have heard of
two others.

The first case was that of a Mexican shot by an Apache, the arrow-head
striking the ulna in its upper third. The man withdrew the shaft imme-
diately, and then came to me. I enlarged the wound, and prudently made
an examination with my finger. The entrance wound of the arrow was on
the flexor side of the forearm, about an inch below and to the inside (ulnar
side) of the coronoid process of the ulna. The ulnar artery was on the
radial side of the wound. On passing my finger down, I readily found the
arrow-head, but it had wrapped itself around the bone, its point being im-
bedded in the periosteal tissues of the outer (radial) side of the ridge on
the posterior surface of the ulna. With a little care, I readily extracted
the missile. Like all such wounds, this one healed readily.

The second case was that of Corporal Scott, shot at Fort Defiance, by a
]N"abajoe. I enlarged the wound, and followed the arrow shaft with my
finger until I reached the iron head. The arrow had entered on the pos-
terior and outer aspect of the leg, penetrated the muscles of the calf, scraped
the fibula about two inches from its head, and then wrapped itself firmly
around this bone. The hemorrhage being very profuse and arterial, I ex-
tracted the foreign body as soon as possible. I then searched for the bleed-
ing vessel (muscular branch of the peroneal), and tied it at one end. The
other I could not find. The wound did well until the second day, when
hemorrhage returned. I failed to find any bleeding vessel, so I used the
anhydrous- chloride of iron, made by the sublimation process, and dissolved
in very strong syrup.* The wound was sponged out, and the solution con-
taining twenty grains of anhydrous chloride, finely powdered, dissolved,
and suspended in strong syrup, injected into the wound by means of a
syringe. This treatment succeeded, and the hemorrhage did not recur.
The man made a tedious recovery.

Dr. Kennon informs us that he had a case of this kind, in which he re-
moved from the thigh of a Mexican an arrow-head which had been lodged
six months previously in the femur. The surgeon attending the man at
the time of the accident, had failed to remove the foreign body, contenting
himself merely with a withdrawal of the arrow shaft. The head had there
produced abscesses, caries, and infiltration of tissues with pus, and the most
serious constitutional symptoms, the patient being brought to the verge of
the grave with hectic. Dr. K. instituted a search for the cause of the mis-
chief, and after a prolonged and bloody dissection, came upon it. He found

' The object in using strong syrup for the solution and suspension of this sub-
stance, is to preserve it anhydrous. Vide an article by author in A7n. Journ. of
Pharmacy, for July, 1858. As prepared in a. strong syrup, we regard this as the
best of tiie hsemostatics.

1862.]

Bill, Notes on Arrow Wounds.

373

that the soft iron of which the head was made, had bent into a semicircle,
and that the femur was half surrounded by this. The doctor extracted the
missile, supported the limb on a splint, applied compresses and bandages,
and administered the proper constitutional treatment. The man recovered
a good use of his limb.

A fourth case, illustrating this peculiar accident, occurred in the practice
of Asst. Surgeon Clements, U. S. A., during the last campaign against the
Nabajoes. A surgeon was shot through the upper part of the posterior
fold of the axilla with an arrow, which penetrated deeply. The shaft was
pulled out, leaving the head imbedded. The man then went to the doctor.
The case was treated by Dr. Clements for six weeks or two months, but
without benefit, and finally it was decided that the arrow-head must be re-
moved. The doctor accordingly made a "f-shaped incision over the sca-
pula, cutting through integument and muscle, and exposing the bone. The
foreign body was, after some search, found, but so twisted and bent, that
notwithstanding the large incisions made, it was only after the application
of some force by strong tooth-forceps, that the head was removed. Second-
ary hemorrhage took place twelve hours after, but was checked by (we
believe) the actual cautery. The man slowly recovered.

We should gladly have given this case in full, had we been acquainted
with all the particulars. It illustrates, in addition to the peculiarity in the
nature of the wound, the proper treatment in all such cases.

If a surgeon is called to a case in which an arrow-head is left lodged in
a bone, and in which, from any cause, immediate extraction is impossible,
what should be the treatment ? Shall cold applications and rest, and all the
usual means for subduing inflammation be enjoined ! We answer, no. In
the first place, such means will be perfectly futile. An arrow-head cannot
become encysted like a ball ; it presents too many sharp angles and edges,
and is too generally irritating for any such event to be expected. Nor
will it become encased in bone. The inflammation which it will always
produce, is the effort of nature to throw off the foreign body, and it cannot
be checked. It will go on to suppuration, abscesses will form, and pus
will burrow, until at length, if some active interference is not interposed, the
member is rendered worthless. In such a case, the treatment must be ex-
pectant. Place the limb on a splint, make the orifice of the wound the
most depending portion thereof, and finally introduce a sponge-tent, or,
what is better, perhaps, a drainage-tube of Chassaignac. From a fair trial
of this instrument in several cases of gunshot wound, we can cordially re-
commend it both in gunshot wounds, and in all wounds where deep suppu-
ration is expected. In addition to a tent or drainage-tube,, bandages and
compresses will be found necessary, particularly towards the conclusion of
the case. They should never be applied so tightly as to produce uneasi-
ness, but should always keep up just that amount of pressure which will
serve to prevent the burrowing of matter, and check motion of the muscles.
Perhaps, after pursuing this course for a while, the arrow-head may be
detected, and if detected, extracted with facility. In any event, frequent
search should be made for it. Generally, we will at length succeed in re-

3t4 Bill, Notes on Arrow Wounds. [Oct.

moving tlie foreign body; but all things else failing, as time, strength,
and patience may, we must operate.

It is not possible to lay down any fixed rules for such an operation. The
incisions should be large and free — boldness rather than prudence govern-
ing our actions. We might as well cut the patient's limb up until we do
find the arrow-head, for if it is left, amputation will be necessary, and worse
than this can hardly ensue from the "cutting up" we have advised. We
would, if we undertook such an operation, make up our mind to find the
arrow-head, even if it were necessary to tear up every fasciculus of every
muscle of the injured member. It is just in such cases as this that the
motto, "Operative surgery is the art of cutting and tying what you cut,"
finds its best exemplification. As such a wound will be attended with hem-
orrhage, rendering all its steps more difficult, it will be proper to compress
the main artery of the limb by the hand of an assistant. Having thus
briefly considered the subject of arrow wounds of parts not essential to life,
let us recapitulate.

1st. An arrow passing through a limb makes a clean half punctured, half-
incised wound, which will generally heal by first intention, if proper treat-
ment be instituted.

2d. An arrow lodging in bone requires some force, much tact, strong
forceps, and an ample incision for its, removal.

3d. This removal should always be effected as soon as possible after the
receipt of the injury, and the greatest care taken in doing so not to detach
the shaft from the head of the arroiu.

4th. Always use the finger to explore the lodgment of an arrow-head,
and to determine whether it is bent or straight.

5th. If we fail to detect or to extract an arrow-head lodged in bone, we
wait a few days, trusting to suppuration, tents, position, etc., and then
search again and again for it.

6th. If we fail in removing the foreign body by these means, we operate,
making large incisions and compressing the artery of the limb.

Let us now proceed to consider arrow wounds of the head. An arrow,
unless it strikes at a short range, or perpendicularly to the skull, will usually
glance off, making a scalp wound — a wound here requiring no particular
notice, as it presents nothing peculiar.

An arrow wound of the orbit will usually be mortal, the missile easily
penetrating the bones of the skull in this situation and then wounding the
brain. We have not seen such an injury, but have been informed by Na-
bajoe Indians that when the Delawares, in 1845, made an invasion of
their country, one of the band was wounded in this manner and died im-
mediately. History assigns King Harold's death to an arrow wound of
the orbit.

If an arrow should strike the skull at a short range and perpendicularly
to its surface, it will probably penetrate. In doing this the arrow-head

1862.]

Bill, Notes on Arrow Wounds.

315

makes in the outer table by compressing the particles of bone surrounding
it, a narrow puncture of the width of the thickness of the arrow-head, and
of the length of the breadth of the same ; a puncture such as it would
make if pushed into a bit of wax. But in addition to this a crack usually
commences from both ends of this puncture, and extends itself in an oppo-
site direction from its fellow, over a distance proportional to the momentum
which the arrow possessed. In its passage through the outer table, the
arrow-head loses its momentum, and strikes the inner table with a greatly
reduced velocity, a velocity not sufficient to allow the arrow-head to pene-
trate it and pass into the substance of the brain ; but enough to cause a
scale of the inner table to be fractured off ; and whilst still sticking to the
point of the arrow-head, to be slightly driven upon (seldom into) the
brain itself. Under these circumstances, the usual symptoms of compres-
sion will arise, as in any other case. The man falls insensible to the
ground. Hence it happens that the surgeon is seldom called to treat
such cases. The man being so wounded and insensible falls an easy prey
to the vindictive savage who shot him, and such a chance is never neg-
lected. If, however, we do have such a case to treat, we remove the arrow-
head and elevate the depressed bone. Both of these indications will usually
be filled by making gentle traction on the arrow-head ; for as the arrow-
head is withdrawn, it draws with it the scale of depressed bone, which is
sticking to its point, until this last is elevated into its proper place. If,
on removing the foreign body in the manner indicated, we find the symp-
toms of compression still present, we infer that we have failed to elevate
the depressed bone. But in any such event we must trephine. We tre-
phine not so much with the purpose of elevating the depressed bone as
with the object of removing the cause of the compression, whatever this
may be. The after treatment of such a case must be mQst strictly anti-
inflammatory, the first signs of cerebral disturbance being met with bleed-
ing and one smart purge. Croton oil has answered best in our hands.
After the elevation of the fragment, close the wound with collodion, shave
the head, apply cold unremittingly, and if inflammation does ensue, as in-
dicated by cerebral derangements, treat it as above indicated. The bleed-
ing, however, must be ad deliquium. If in any case suppuration should
commence, and abscess form, then also we must resort to the trephine.
Such a case will almost surely end fatally.

Miguel " Nigro," the post-guide at Fort Union, was shot with an arrow
by a Utah Indian. I found the arrow-head sticking in the left parietal
bone, the shaft having been detached. I made traction on it, and drew it
out of the wound. The symptoms of compression present at once vanished,
the man turned over and sneezed, and rose up on his feet. I had made
arrangements to trephine the skull if necessary, but I had probably restored
to its proper level that portion of the inner table which was depressed, so

316

Bill, Notes on Arrow Wounds.

[Oct.

that measure was unnecessary. The cause of the compression was gone,
and I had nothing to trephine for. The next day the man complained of
headache. His face was flushed, eyes suffused, pulse hard, and irregular.
I ordered croton oil, shaved his head, and applied cold. Presently, when
delirium came on, I bled him until he fainted. This bleeding was repeated
the night of the same day. The next day he was greatly better ; the croton
oil had operated well. The man was left to recover, which he did in three
weeks.

We have examined two other cases of arrow wound of skull. In both,
the subjects were dead. In both there was a depression of the inner, with
a fissure of the outer table. In one of the cases the wound was over the
right frontal bone, and this was fissured into the coronal suture. The de-
pressed portion of the inner table measured a half inch in diameter, and
was firmly attached to the point of the arrow-head, so that on withdrawing
this latter, I could readily elevate the depressed scale. The second case
was that of an Indian, shot with an arrow, in one of the Wormian bones.
The inner table was just barely pierced by the arrow-point. The fragment
of bone depressed was driven upon the membranes over the left posterior
cerebral lobe, without, however, tearing these. In neither case was hemor-
rhage observed ; neither died immediately.

Lieutenant Maxwell was shot in the head by an arrow which penetrated
his skull, wounding the brain, and killed him almost immediately. We did
not see the case, and, therefore, we refrain from noticing it farther.

Arrow wounds of the trunk, from their greater importance and more
frequent occurrence, comprise the greater part of our subject. The Indians
know well the fatality of such wounds, and aim always at the umbilicus ;
hence one cause of the frequency of these wounds.

An arrow sqpietimes goes through the chest and passes out. It would
always do so if it were not that it can scarcely miss hitting a bone. Hence
it happens that a lung is not nearly so often wounded by an arrow as an
intestine. Of fifteen cases of arrow wound of chest falling under our no-
tice, in New Mexico, in seven cases only was the lung wounded, and in one
of these, the heart was wounded also ; and in four of these (rejecting the
case complicated with heart wound) the patients died. In two, the death
was by hemorrhage; in one, by empyema; in one by pneumonia, complicated
with peritonitis.

An arrow wound of lung is from first to last more dangerous than a
gunshot wound of the same parts. There are three reasons for this. First,
the hemorrhage occurring at the time of the injury, or a few hours after, is
much more profuse than in an ordinary gunshot wound. A ball going
through the chest does not often give trouble from hemorrhage, unless it
should wound a large vessel. The reason is, that a ball tears and bruises,
while an arrow makes clean slits and punctures. Secondly, an arrow

1862.]

Bill, Notes on Arrow Wounds.

S11

wounding the lung, is almost sure to lodge, whilst a ball generally passes.
Now, hear what Guthrie says about balls that lodge in the chest.*

''General McDonald, of the Royal Artillery, was present at Buenos
Ayres when a bombardier of that corps received a wound from a two
pound shot, which went completely through the right side, so that when
led up to the general, who was lying on the ground, he saw the light quite
through him, and supposed, of course, that he was lost. This, however,
did not follow, and some months afterwards the man walked into General
(then Captain) McDonald's quarters so far recovered from the injury as to
be able to undertake several parts of his duty before he was invalided, thus
proving the advantage of a shot, however large, going through rather than
remaining in the chest.'' ^

Why is this ? Is it feared that a ball lodging will be more apt to in-
duce pneumonia than one passing completely through the chest ? Is it
hemorrhage from wounded lung that is so much feared ? No ! It is the
danger of exciting and keeping up a low form of inflammation of the
pleural sac, such as is sure to lead to effusion of serum, and then to collec-
tions of pus in its cavity. In a word, it is the danger of empyema.
Guthrie says of this^ : ''It is the great fact to be attended to in the treatment
of pistol wounds of chest, or those made by small balls which do not pass
through." Now if this applies to balls, it applies to arrows in a higher
degree. If an arrow-head becoming detached from its shaft is permanently
lodged in a vertebra, or a rib, empyema will result. The third danger
peculiar to arrow wounds of lung is the supervention of emphysema twelve
or fifteen hours after the receipt of the injury. It is rather an inconveni-
ence than a danger.

In an attack made by a company of Mexicans on the Nabajoe Indians,
thirty men were wounded, and twenty-two killed, or died of their wounds.
Many of these cases were wounded by arrows. They all came under the
writer's care. Of arrow wound of lung there were in all five cases ; three
of these died, two recovered.

Case I. Name unknown. Man found dead among many others ; skull
uninjured. Three arrow wounds, of which two wounded the lungs. Ground
covered with pools of this subject's blood. Chest, on being opened, was
found as follows : About two pounds of semifluid blood were found in left
pleural sac, and a somewhat smaller quantity in the right. Bronchi, in
places, engorged with blood. No large vessels injured. One arrow had
lodged in the body of a vertebra. It had entered below the right nipple.
The other arrow went through the chest from right to left and passed out.
Subject was probably asphyxiated with blood.

Case 11. Salvador Martinez, shot through chest with an arrow which
entered between the fifth and sixth ribs on the right side, and passed out
between the seventh and eighth on the left. The man vomited blood.

* Guthrie's Commentaries, p. 480.

2 Commentaries, p. 473,

3t8

Bill, Notes on Arrow Wounds.

[Oct.

Arrow had been extracted when I saw him. I had him taken to Fort
Defiance, where he arrived very much exhausted. He rallied, however,
and took a half a grain of sulphate of morphia at bedtime. The next
morning an ordinary domestic enema was used, and the rectum washed
out. As the stomach had evidently been wounded, I deemed it improper
to .allow nourishment to be taken into that organ. Accordingly, after the
enema, about a half pint of beef essence and two ounces of wine whey were
thrown up per anum and retained. Half a grain of morphia was then
administered, and the patient left to repose. At 9 P. M. I found the
patient's respiration very much embarrassed. There was pain and dulness
on the left side; vesicular murmur absent. I opened by a probe the wound
in the left side (which I should have stated had been closed with soft leather
soaked in collodion), and so caused the discharge of a large quantity of
blood, serum, pus, etc. ; then cautiously enlarged this wound, and intro-
duced a sponge tent. The difficulty and pain on breathing now ceased, and
the respiration on the right side, which had been puerile, became vesicular.
I now easily detected incipient pneumonia. I therefore ordered twelve cups
to the chest, and f5iss of tinct. opii, in a starch enema, to relieve pain.

The next day at t A. M. found the patient better ; had slept a little, and
has appetite. The rectum having been unloaded, twelve ounces of beef
essence were injected. On removing the tent, the wound discharged some
matter. Laudanum enema repeated at 9 P. M. The next morning at T
A. M. found the man very uncomfortable and anxious, and complaining of
colicky pains. Right lung was solidified, as it was dull on percussion,
and tubular blowing was present. Sputa adherent to the vessel and more
purulent. Pulse 110, and great pain on pressing the epigastric region.
Twelve cut cups ordered ; and at 2 P. M. beef essence enema. At 9 P. M.
the patient was worse, peritonitis being well pronounced. The patient
sinking; pulse 125, and very feeble. For the peritonitis, ordered sulphate
of quinia, in ten grain doses per anum, in beef essence. Two enemata to
be administered during the night. The next day at 7 A. M. the patient was
a little better, but very weak. Ordered the quinia to be continued, and
wine whey in enemata, every two hours. The patient had rejected iced
champagne from his stomach. The sputse were very tenacious ; adhered to
the vessel in which they were placed when it was inverted. Wound in left
side discharging prodigiously. Has pain on pressure over the abdomen. At
9 P. M. found the man suffering considerably. Ordered a laudanum enema,
the quinia to be given at 4 A. M. JN^ext morning he was free from pain
and much better. Quinia in small doses to be continued ; beef essence and
wine whey to be plentifully supplied. This treatment was continued until
the patient's death, on the sixteenth day. The peritonitis yielded on the
tenth day to the quinia treatment.

An inspection of the parts concerned showed the right lung solidified
and engorged with pus. Left lung contained a cavity of the size of a
turkey's egg, and was also much disorganized from the presence of pus in
its tissue. The arrow had wounded the right lung, the liver, the stomach
at its posterior and cardiac aspect, and, finally, the left lung. The wound
in the stomach had healed, but the diaphragm contained two slits in it.
The wound in the liver was open and communicated with the wound in the
right lung. There were signs of recent general peritonitis.

Case IIL Santiago Orliz was shot in the left armpit by an arrow. The
shaft of the arrow had been pulled out two days before I saw him, leaving

1862.]

Bill, Notes on Arrow Wounds.

379

the head firmly lodged in the fourth dorsal vertebra. The hemorrhage, I was
informed, had been very great. His Mexican comrades restrained it by
plugging the wound. I made an examination with a chest probe, but
failed to detect the foreign body. I gave up the search, enlarged the
wound, introduced a common tent, and contented myself with an expectant
plan. In three days the Avound discharged matter in large quantity. I
again searched for the arrow-head but without success. The wound was
made the depending part of the body, and I hoped that the foreign sub-
stance might make its way out, and, moreover, that empyema might be
thus prevented. But all in vain, the man died asphyxiated from inability
to throw off by his mouth the matter which was constantly being coughed
up. Inspection ten hours after death showed a wound between the fourth
and fifth ribs. The track of the arrow had healed for an inch or more, and
thence was open to the fourth dorsal vertebra, which was found to have
been wounded, the wound being filled up with a cartilaginous cicatrix.
The pleural cavity was distended with matter, but did not communicate
with the external wound ; the pleura costalis and the pleura pulmo-
nalis being united at this point. The pleural cavity communicated with the
fistulous track in the lung tissue. I was deceived in this case ; I supposed
that the external wound would allow of the drainage of all the matter
that could form, whereas, in fact, it did not allow of any discharge at all
from the pleural cavity. I should have been more attentive to the physical
signs in this case, and at least have made an exploratory puncture to deter-
mine the presence or absence of matter in the pleural cavity, and then I
would have performed paracentesis. I found the arrow-head resting on
the diaphragm, it having ulcerated through the pleura, and I have no doubt
that in time it would have perforated the diaphragm and slipped into the
abdominal cavity. It was very crooked ; the long thoracic artery had been
divided by the arrow-head, but no vessel of importance was injured.

Case IY. Private Connor, of the third infantry, was shot by Nabajoes
with four arrows, all through the lung. He was alive when I reached him,
but died in a few minutes, apparently asphyxiated with the torrents of blood
pouring into his bronchi. I found the vena cava descendens pinned to one
of the vertebrae by an arrow-head. The aorta was pierced by a small
arrow-head, the wounds in the vessels being plugged perfectly by the arrow
shaft.

The lung may be wounded with arrows in several places, and yet the
patient recover.

Case Y. A Mexican, name unknown, whilst travelling the road near
Fort Defiance, was shot by jSTabajoes with five arrows, all the arrows in-
juring the lung, and one of them passing through the upper border of the
liver. I saw the man twenty minutes after the accident. The bleeding
was most profuse, and the man fainted. Both lungs were wounded ; I
made the worst possible prognosis, but proceeded to extract the arrows, all
of which I safely removed. After the hemorrhage had ceased, I applied
muslin soaked in collodion to each of the wounds, eight in number, and
had the patient put to bed, and given a grain of morphia. The next morn-
ing the patient was more comfortable than I had expected. He had been
vomiting, and I gave him some acetum opii and acetate of lead, to quiet
this and restrain secretion. In the afternoon the man complained of pain
on the right side, and difficulty in breathing. I removed the dressing from
the wound, involving the liver and lung, and broke up some clots where-

880

Bill, Notes on Arrow Wounds.

[Oct.

upon a considerable quantity of mixed fluids were discharged from the
wound. These contained bile as I discovered by Pettenkofer's test. This
procedure greatly relieved him, and he expressed himself much better. I
ordered the prescriptions of the morning to be repeated. The next day the
patient vomited a considerable quantity of black decomposed blood, and
complained of the frequency of his urination. Urine very dark coloured,
sp. gr. 1036; urine contained cholic acid and sugar. All medicines ordered
to be discontinued. After this the patient gradually recovered, all the
wounds healing by first intention, except that implicating the liver, and
that ceased discharging on the sixth day. In two weeks the man left the
hospital, his urine still containing sugar, but no bile. He had passed dur-
ing his illness about thirty-six ounces per diem. In a few days the last
traces of sugar disappeared from his urine, and in six weeks from the day
he was wounded, he returned to the post from a scout, in order to have
removed a large polypus of nasal cavity, which had plagued him a great
deal during his sickness.

This case is remarkable, showing, as it does, what iujuries a .man may
sometimes survive. It also proves that wounds of the lungs sometimes
heal by first intention,^ and it illustrates a common occurrence after liver
wounds, the presence of bile and sugar in the urine. It shows, moreover,
that the hepatic peritoneum may be wounded by an arrow without death
resulting, or the effusion of blood or bile into the cavity of the abdomen.
Finally, it is a good example of the treatment proper in such cases. In
this instance, as well as in two of the fatal cases of arrow wound of lung,
emphysema was present. It was not particularly treated, save that, when
possible, Guthrie's rule was observed, the patient lying on the wounded
side.

If an arrow, passing through the lung, lodges in a vertebra, it is very
apt to be fatal. For, independent of the danger of a wound of the lung
itself, or of laying open one of the great vessels, or of penetrating the
spaces between the vertebra, and so injuring the medulla spinalis, there still
remains the danger that the head may become detached from the shaft of
the arrow, and be left sticking in the bone. The prognosis in all cases
must be very guarded.

In addition to the third fatal case of arrow wound of chest before men-
tioned, we know of four others, not so well authenticated, it is true, but

^ We liave noticed in Isew Mexico a great tendency of all wounds to lieal by
first intention. In an operation undertaken for the removal of an encliondrome of
the vomer, involving a long and disfiguring incision on the face, the wound healed
throughout by first intention and scarcely a sign of a cicatrix was left. Assistant
Surgeon Irvin has called the writer's attention to the fact that in this country,
gunshot wounds sometimes heal in this way, and although we have seen nothing
of this kind ourself, we are yet very sure that all wounds heal much more quickly
here than at the seaboard. When inflammation does occur it takes a typhoid
type. I have not seen a case of sthenic inflammation in the country. It is
necessary to remove sutures on the second day. If left longer they slough out.
We nearly failed in a case of harelip by neglecting, or rather through ignorance of,
this fact.

1862.J

Bill, Notes on Arrow Wounds.

381

in whicb, from a careful inquiry among the friends of the deceased, we were
persuaded that death resulted from empyema, the consequence of an arrow-
head lodged in the walls of the thorax ; we say not well authenticated,
because we did not examine the bodies of the wounded men. We have not
recorded these among the fifteen cases of wounds of the chest, although
there is no doubt that one case out of fifteen is too small a proportion of
deaths by empyema.

Let us now inquire into the treatment of an arrow wound of the chest.
Take the following case which has occurred in the practice of the writer.
I was called to a man shot with an arrow ; the shaft was broken off close
to the wound, and the splintered ends of the shaft closely resembled a
splinter of a fractured rib. As soon as reaction was established (and
shock is often severe in arrow wounds of lung) I attempted the removal
of the missile, not by catching hold of the broken arrow shaft with
strong forceps, and making traction with these, for if I had done so, I
would inevitably have left the arrow-head in the wound. The first step
in the removal of such a weapon is to ascertain its seat, its connections, its
lodgment. First, it is proper to determine how deeply the arrow has pene-
trated. This can be done by measuring the length of the shaft sticking
out of the wound, and deducting this from the total length of an arrow
shaft of known length. The Nabajoe and Utah arrow is about two and a
half feet long. The Apache, Camanche, Arrapahoe, Cheyenne, Kiowa,
and Pawnee arrows are about two feet and three-quarters in length. Next
we wish to determine whether the arrow-head is fixed in bone or not. Take
the shaft between the finger and thumb, and gently twirl this. If the
arrow-head is fixed, we can readily discover the fact by this motion. We
then should notice its direction, and whether, considering the depth it has
penetrated, it has wounded any great vessel. Here our anatomical know-
ledge avails us everything. We notice whether blood wells up along the
side of the shaft, on pressing this latter aside. We determine whether
the head has lodged in a vertebra, or a rib, and if in the last-named, in what
rib, and in what part of that rib. We ascertain the exact seat of an arrow
lodged in a rib, by first determining the rib, which is sufficiently easy, and
then percussing gently the extremity of the arrow shaft with one hand,
whilst a finger of the other is gently slid along the wounded rib backwards
and forwards, until the point of greatest impact is determined ; this is the
spot where the arrow-head is lodged. All this having been settled, we may
arrive at a prognosis. In the case we have referred to, I went through all
these examinations. I found that the arrow shaft broken ofi", measured two
feet and one inch, and I concluded that the lung was wounded to the depth
of five inches. (It was a Nabajoe arrow.) The orifice of the wound was in
the space between the fourth and fifth ribs, on the right side. The general
direction of the shaft seemed to be that of a line drawn from the nipple to
the inferior angle of the scapula. On twirling the shaft, by seizing the

382

Bill, Notes on Arrow Wounds,

[Oct.

broken end of it with tooth-forceps, I found that the point was not lodged
in bone. There was no hemorrhage, and the patient rallied from the shock
quickly. In this case the prognosis was good, that is, for such a wound.
A probe-pointed bistoury was used to enlarge the wound to the extent of
an inch, keeping in view the situation of the intercostal arteries, lying as
they do on the upper border of the rib in the first two inches of their
course previous to their division, and after this division in the larger
branch, sheltering itself beneath the lower border of the rib above it ; a
wire having a loop at the end, and bent at a right angle, was introduced,
and pushed down through the wound (using the arrow shaft as a guide),
until its loop was past the point of the iron arrow-head, and then slipping
the loop over the point of this, and drawing the wire gently back, it was
found from the sense of resistance that the loop had snared the treacherous
body. Figure 1 illustrates better than words can describe, what is meant.

Fig. 1.

Extraction was of course sufficiently easy. Gentle traction applied to the
arrow shaft and to the wire at the same time, sufficed to remove the arrow,
without detaching the shaft from the head. The wound was then closed
up with collodion dressing, and the patient directed to lie on the wounded
side. Inflammation succeeded, but as it was not excessive, I was contented
merely with watching it.

Suppose that from the difficulty in breathing, external welling up of
blood, and, above all, the depth or direction of the wound, and the con-
tinuance of shock, it is made evident that a large vessel is wounded. In
such a case there is, of course, no hope. Any interference with the arrow
is injudicious,, for if we were to extract it under such circumstances, in all
probability death would result immediately. We can merely make the patient
a little more comfortable in the few hours that are left to him.

If from the depth to which an arrow has penetrated, and from the
direction it has taken, and more particularly, if on gently twirling the
shaft between the finger and thumb, it is found that the arrow-head has
lodged in bone, we must modify our proceeding. The first thing to be done
is to determine accurately whether the foreign body has lodged in a vertebra,
or in a rib. Here our anatomical knowledge must serve, together with the
direction taken by the arrow. Suppose it is lodged in a vertebra, what is
to be done ? We enlarge the wound, as before ordered, and then very cau-
tiously attempt to loosen the head from the bone in which it is lodged, by
gently rocking the arrow shaft, held between the fingers, backward and for-
ward. In what direction is it best to do this, in order not to loosen the
head from' the shaft of th A arrow? If the arrow of any particular Indian
tribe is examined, it will oe found that the tribe always makes the two

1862.]

Bill, Notes on Arrow Wounds.

383

slits in the arrow shaft — the one for the string, the other for the stem
of the arrow-head — either in the same plane, or in planes at right angles
to one another ; most Indians make them in the same plane. Thus the
plane of the broad surface of the arrow-head always holds a fixed relation
to the plane of the notch for the bow-string. To make this more evident,
suppose the head is removed from the shaft of an arrow, and a straight bit
of wire put in its place, at right angles to the shaft of the arrow, and
another bit of wire laid in the notch for the bow-string ; what we intend
• to state is that these two wires will point in the same direction, or else in
a direction at right angles to one another. Before touching the arrow
shaft, we notice what the direction of the plane of the notch for the bow-
string is, whether it is horizontal or perpendicular, or between these two.
We then know that the notch in the other end of the arrow bears a fixed
relation to this, and is either in the same plane, or in a plane at right angles
to it, according to the way in which the arrow is made by the tribe of In-
dians to which the arrow belongs. Having determined exactly what the
plane of the notch for the head is, we should now rock the arrow shaft to
and fro in a direction at right angles to this plane — ^the plane of the broad
surface of the arrow-head. In this way the chances of loosening the head
from the shaft are diminished. There are two places at which yielding may
occur ; either at the place where the shaft is attached to the arrow-head by
the tendon, or else at the place where the head is implanted in the bone.
Whatever the theory may be, the practice is to rock the arrow shaft in a
plane at right angles to the broad surface of the arrow-head, and not parallel
to it. This rocking motion should be both gentle and slight, and may, if
these conditions are observed, be persevered in for some time. The Mexi-
cans, in their frequent encounters of the Indians, have become aware of
what has just been stated, and they apply it successfully to the extraction
of arrows lodged in bone. We know of several instances in which it has
been so applied by the Mexicans. Generally, however, it will fail, and if
undue force is used the head and shaft of the arrow are sure to become
detached from one another. If we succeed, we remove the missile in the
same manner as we do an arrow-head not lodged in bone. Supposing,
then, we have failed in this plan, what is left us ? It will not do to allow
the arrow-shaft, head and all, to remain in the wound till it becomes loos-
ened by suppuration. The patient will be sure to perish of pneumonia.
We have never had a case of this kind to treat, but have made numerous
experiments on the cadaver with various kinds of forceps and other con-
trivances, and we have come to the conclusion that the following plan will
suffice for the removal of arrows lodged in a bone within the cavity of the
chest or abdomen most easily to the surgeon and most safely to the patient.

Procure a piece of very well annealed iron wire a little larger than the
coarsest usually employed for sutures. Let this be about two feet and a
half in length. Pass the ends of this wire through the holes in a very long

384

Bill, Notes on Arrow Wounds.

[Oct.

Cogliill's suture wire twister (Fig. 2), and carry them up the shaft of this,
securing their ends to the handle.^ The loop at the end of the instrument

Fig. 2.

made by the doubling of the wire should now be once twisted on itself and
then bent at right angles to the shaft of the instrument. (See Fig. 3.)

This shaft should be at least one foot in length.
Then, the wound being suflSciently enlarged, we
pass the loop at the end of the twister over the
feather end of the arrow-shaft, and using this
last as a guide, we push the instrument straight
on till the loop of wire is carried beyond the
arrow-shaft and is encircling the arrow-head.
We now draw on one of the ends of the wire so as to make the loop
embrace the arrow-head tightly, and then we secure the end of the wire to
the handle of the instrument. One or two twists of this will now suffice
to tighten the wire so that it cannot slip off from the arrow-head, and all
that is now necessary is to make firm but gentle traction on the handles
of the twister, gently rocking the arrow-shaft to and fro at the same
time, in order to disengage the head of the arrow from the bone. We
have never failed to extract an arrow-head lodged in bone within the tho-
rax by this method. If' the arrow-head is very firmly imbedded in the
bone it will be well to throw two loops of wire by two twisters over it
before making traction. In such a case traction is best made by fastening
the handles of the two twisters to an inflexible rod, placing a block or pile
of books resting on the patient's thorax under one end of this, and then
applying force to the other end. In a word, in such cases it is well to use
a lever of the second class to pry out arrow-head, shaft, wire loop, and
twister, all together. No forceps ever constructed could be used successfully
in such a case. The after-treatment of such cases presents nothing pecu-
liar. The patient must be well guarded against shock.

It is not easy by this method to extract an arrow-head which has passed
through one side of the chest and lodged in a rib on the other, although
such a wound as this is probably mortal. If the patient survive the shock
and hemorrhage, the best plan for extracting the arrow-head is the follow-
ing: Determine exactly by the process previously given, the part of the rib
in which the arrow-head is lodged, then apply the trephine to this part of

' A couple of silver catheters straightened and soldered together so as to resem-
ble a large'sized double canula for hsemorrhoids will answer in place of Cogliill's
instrument.

1862.]

Bill, Notes on Arrow Wounds.

885

the rib, taking care not to injure the intercostal artery in its lower border.
It is very easy to make the opening in the rib within the eighth of an inch
of the arrow-head; sometimes we can hit the spot exactly, and on attempt-
ing to withdraw the circle of bone we find the arrow firmly imbedded in it.
Nothing else is necessary than to cut off the part of the arrow-shaft which
protrudes from the right side and draw the remaining portion out through
the wound in the rib. But, as was before remarked, the prognosis in every
such case is very unfavourable.

Arrow wounds of heart are generally fatal, although not always instan-
taneously so. In one case falling under my notice the man perished
instantly. I found the ventricles of the heart and the descending aorta
pierced by an arrow and spiked to a rib. In another case the man lived
five minutes. The case was interesting in a medico-legal view, as it was
devolved upon us to determine whether the man had been shot with a pistol
ball from the weapon of a comrade, or with an arrow, so much did the
wound resemble that made by a navy-sized Colt's revolver. I found the
arrow-head lodged in a vertebra. It had pierced the top of the auricle.

Arrow wounds of abdomen are generally fatal. An arrow can scarcely
pass through the abdomen and fail to open a vessel or wound an intestine.
We have seen twenty-one cases of arrow wound of the abdomen. All
save one, of those cases in which the abdominal cavity was implicated,
terminated fatally. In three the integuments only were wounded, and in
one the arrow had lodged in the crest of the ilium without wounding an
intestine.

Of the seventeen fatal cases, thirteen perished from peritonitis and four
from hemorrhage. All save two were wounded in the intestine, although two
of those so wounded died from hemorrhage. Nine of the cases of perito-
nitis had been exposed to a broiling sun, without water, for two days. Five
were dead, and none lived to reach the Post. The remaining four cases of
peritonitis occurred in the persons of United States soldiers engaged against
Nabajoes. In all, fecal matter was found discharged into the peritoneal
cavity, the intestine being wounded.

The Mexicans, on entering into an Indian fight, wrap many folds of a
blanket around the abdomen. Thus it happens that an arrow, after pene-
trating these folds, has not momentum enough left to do more than wound
the integument, and fails to reach the abdominal cavity.

From all that has been stated it must appear that the prognosis in all
cases of arrow wounds of abdomen is very unfavourable. Much, however,
will depend upon the seat and extent of the injury, and upon the facilities
for treatment and transportation. The treatment should take into con-
sideration the extraction of the missile, the checking of hemorrhage, the
removal of any discharged excrementitious matters, the suturing of the
wounded intestine, and the preventing or suppressing of peritonitis. If
No. LXXXYIII.—OcT. 1862. 25

386

Bill, Notes on Arrow Wounds.

[Oct.

the arrow-head is lodged on feces extruded through the wounded intestine,
we consider that no surgeon should be satisfied without operating. It is
difficult, however, to arrive at this information with certainty.

If called to another case of arrow-wound of abdominal cavity we would
feel almost justified in enlarging the wound, laying open the abdomen,
searching gently for wounded intestine, and removing the arrow-head if
lodged firmly in bone, with strong short forceps. In any event, if this is
not done the patient will die. For suturing the intestine we should look
upon very fine gold wire with great favour; on gold wire because this
metal is possessed of greater ductility than any other. If we are certain
that an arrow-head has lodged in a bone of the pelvis, the course above
indicated must be pursued, for in addition to the facility which an en-
larging of the wound gives for extracting the arrow-head, there is thus
afforded also an opportunity of suturing intestine requiring it, of removing
foreign matters, and perhaps of checking hemorrhage. If it is decided
upon to adopt an expectant plan, and, in fact, after any operation for re-
moval of arrow-heads, opium must be given in full doses very frequently,
until narcotism ensues, and starvation and absolute rest must be enforced.
The patient must not be allowed to rise from the recumbent position for
at least two weeks, and milk and light custard must be his only diet. We
know of at least one instance in which an officer lost his life by insisting
on leaving his bed before the tenth day. In every case, however, of arrow
wound of abdomen, it is necessary to remember that the arrow-head must
be extracted or the patient will die. It is the great distinctive rule between
arrow and gunshot wounds of all other parts of the body as well as of the
abdomen, always to extract the foreign body, if it he an arrow.

Such, then, are arrow wounds as we have seen them — a class of wounds
as troublesome to the surgeon as dangerous to the patient. But in no class
of wounds does surgical skill avail the patient so much or reward the sur-
geon so well for his trouble. Only never let him despair of his patient
until he has operated in vain. An expectant treatment in such cases is
really no treatment at all.

We wish in conclusion to recommend to those in authority the plan of
protecting soldiers and others exposed to arrow wounds with a light cuirass.
The Indians have a method of dressing bulls' hide for shields for themselves,
which renders it arrow proof. A cuirass made of such material, protecting
the whole trunk before and behind, need not weigh more than eight or ten
pounds, and by means of it a soldier could enter an Indian fight with a
fair chance of escaping death. Or perhaps the recently invented ''bullet-
proof vests" might be found better adapted to the service and equally effect-
ive. Certainly it is policy in fighting any enemy to make it as safe for
ourselves as possible, and as dangerous for him. Sooner or later the go-

1862.] Salisbury, Inoculation with Straw Fungi. 381

vernment must undertake some great expedition against all tlie Indians of
the plains. It may be possible to civilize Creeks, Choctaws, Cherokees, etc.,
but with a Cheyenne or Camanche or Apache the attempt will surely fail.
The hands of these Indians ever have been and ever will be against every
man. They are the professed exponents and great advocates of barbarism
and universal ignorance. In view of any such plan of a general civilization
of these tribes we think it should be the care of those who control such
things to provide, as far as possible, for the safety of the soldier. We are
certain that if suitable bulls' hide cuirasses were provided fatal wounds
from arrows would become very rare. In all commands engaged against
Indians an order should be issued warning the men of the danger of
attempting to extract an arrow, and directing them in all such cases to go
at once to the surgeon in attendance for assistance. From what has been
already written, it is easy to see how great an advantage such a course will
give a surgeon in the treatment of the injury.
FoKT Ckaig, New Mexico, Jan. 1, 1862.

Art. III. — Inoculating the Human System ivith Straw Fungi, to protect
it against the Contagion of 3Ieasles ; ivith some Additional Ohservations
relating to the Influence of Fungoid Groivth in producing Disease and
in the Fermentation and Putrefaction of Organic Bodies. By J. H.
Salisbury, M. D., of Newark, Ohio.

In the July number of this Journal, I presented some remarks on
fungi, with an account of experiments showing the influence of straw
fungi upon the human system, etc. At that time I had inoculated but
thirteen cases. Since then there have been inoculated 27 additional cases,
all of which were situated under the most favourable circumstances for
testing rigidly the prophylactic virtues of inoculation with straw fungi, in
protecting the human system from the contagion of measles.

About the 30th of May, 1862, measles made their appearance among
the boys of the Ohio State Reform Institution, situated in Fairfield County,
Ohio. They were introduced into the establishment by a boy who was
taken into it before he had entirely recovered from the disease. The officers
in charge were not acquainted with the fact till it was too late to remedy it.

June 2d, Prs. Effinger and Boerstler, of Lancaster, 0., were called to
examine the first cases. They at once pronounced the disease measles.
June 4th, I received the following letter from Dr. Boerstler.

Lancaster, June 2d, 1862.
My dear Sir : Sorry you have left. To-day was called in consultation,
to Reform Farm, where they have lt5 boys, twelve taken down with

388

Salisbury, Inoculation with Straw Fungi.

[Oct.

rubeola, many more to take it. I hunted the farm over for fungi. No
straw. Got very poor mould of clover. Had Dr. E£6nger to introduce
it into three boys, all of whom sleep in the room where those do who
have the disease. No better opportunity to test ; I wish I only had good
fungi from straw. Will hunt it up, and try fairly. I wish you were here
to experiment for weeks. Will give you the desired information as soon
as at leisure.

I am truly yours,

Dr. J. H. Salisbury, Newark, 0. BOERSTLER.

On June 5th, I started for Lancaster, and arrived there about noon.
Saw Dr. Boerstler, and made arrangements to visit the State Farm with
Drs. Effinger and Boerstler on the following morning, June 6th. I had
with me mould from wheat and rye straw which was grown in a box in my
ofiBce. The fungi were grown about three weeks previously, and had been
left in the box — in a mature state — upon the straw. The whole plants
with the spores were carefully removed from the straw and placed between
plates of glass on the 3d of June.

On the morning of June 6th, we repaired to the State Farm. Professor
Howe, principal of the institution, had kindly extended to Dr. Effinger,
the attending physician, and Dr. Boerstler every facility the case in hand
afforded for testing the prophylactic virtues of straw fungi in protecting
the human system from the contagion of measles.

We accordingly selected twenty-six fine healthy boys, who had never had
the disease, and inoculated them. There were 115 boys in the institution,
ranging in age from eleven to sixteen ; and these were divided into four
families, each family occupying a building by itself. In each building was
one large sleeping room, in which all of a single family slept. Cases of
measles had occurred in every family, exposing every boy in the establish-
ment to the contagion of the disease. Twelve boys had already had the
measles, and were so far recovered as to be out, and six were still in bed
with the disease.

Cases Inoculated. — Case I. Fred. Abraham (Cuyahoga family).
June 6. Inoculated with rye straw fungi.

dth. Redness of inoculating wound slight. Blotch two lines in diameter ;
no red lines radiating from v/ound.
12fh. Blotch dried. Well.
mh, im., im, and 24:tJi. Well.
July 22c?. Has had no symptoms of measles.

Case II. Albert Kelso. (Cuyahoga family.)
June 6. Inoculated with fungi of rye straw.

Wi. Redness slight. Blotch four lines in diameter ; red lines radiating
from the wound. Eyes slightly vascular.
12ih. Blotch dried; had cough and coryza.
mh, im, 19//?, and 24//?. Well.

Case III. Silas Fond. (Scioto family).
Ju7ie 6. Inoculated with fungi of rye straw.

1862.]

Salisbury, Inoculation with Straw Fungi.

389

^th. Well, and out with force ; was not seen.
\Wi. Well ; out with force ; was not seen.
Ibth. Well. Blotch dried.
im, mil, and mh. Well.

Case IY. Edward Blakeley. (Scioto family.)
June 6. Inoculated with fungi of rye straw.

9ith. Inoculating wound red. Blotch four lines in diameter ; red lines
radiating from wound.

\Wi. Well \ out with force ; was not seen.
Ibth. Blotch dried and well.
im, mil, and Uth. Well.

Case Y. August Gibing. (Scioto family).

June 6. Inoculated with fungi of wheat straw.

^th. Redness slight ; no red lines radiating from the wound.

12th. Well; out with force ; not seen.

Ibth. Well ; blotch dried.

im, im, and Mth. Well.

Case YI. Levi Wilson. (Hocking family).
June 6. Inoculated with fungi of wheat straw.
^th. Well ; out with force ; was not seen.
12z^/i. Well; out with force ; was not seen.
Ibth. Well ; blotch dried.
lUh, mh, and mh. Well.

Case YII. Thomas Collins. (Cuyahoga family).
June 6. Inoculated with the fungi of wheat straw.
^th. Working well ; blotch four lines in diameter ; red lines radiating
from the wound.

12th. Blotch dried and well.

Ibth. Well ; at work with the force ; not seen.

im, im, and mh. Well.

Case YIII. Earner Greener. (Cuyahoga family).
June 6. Inoculated with fungi of wheat straw.

Wi. Doing well ; blotch four lines in diameter ; red lines radiating from
the wound.

IWi. Well ; working with the force ; not seen.
Ibth. Well ; blotch dried.
im, mh, and 2ith. Well.

- Case IX. James Hill. (Scioto family).

June 6. Inoculated with fungi of wheat straw.

%th. Blotch the size of a five cent piece. Red lines radiating from the
wound.

\Wi. Well ; working with the force; not seen.

Ibth. On the night of the 12th an eruption appeared in patches on his
arms ; it appeared next on his face ; next on his legs and thighs ; and
lastly on his breast ; sickness shght.

\Uh. The blotches were about one line in diameter, circular, and about
half an inch apart. They were distributed in patches over the whole body.
The eruption was still plainly visible on the face and body. There was no
smell whatever to the disease. Sickness slight from the commencement.

l^th and 2ith. Well, and working with force.

390

Salisbury, Inoculation with Straw Fungi.

[Oct.

Case X. George Brown. (Scioto family).
June 6. Inoculated with fungi of wheat straw.
9^/? and IWi. Well; working with force; not seen.
mil. Well; blotch dried.
16^/i, 19^/?, Uth. Well.

Case XL Joseph Townsend. (Scioto family).

June 6. Inoculated with fungi of wheat straw.

9^/i. Blotch small ; slight red lines radiating from the wound.

\2th. Blotch dried; had some cough and corvza.

Ibth, mil, im, and ^Uh. Well.

Case XII. Miles Parmeter. (Cuyahoga family).
June 6. Inoculated with fungi of wheat straw.
9//i and IWi. Well ; working with force; not seen.
15//?. Well ; blotch dried.
im, im, and mil. Well.

Case XIII. John Lawrence. (Scioto family).
June 6. Inoculated with fungi of wheat straw.

Wi. Doing well ; blotch four lines in diameter ; red lines radiating from
the wound. Eyes vascular.

12;*/?. Well; working with field force; not seen.
15//?. Well ; blotch dried.
16//?, 19//?, and 24//?. Well.

Case XIY. Thomas J. Fransted. (Scioto family).
June 6. Inoculated with fungi of rye straw.

9//i. Blotch looks well ; size of a three cent piece ; red lines radiating
from the wound ; eyes sensitive.

12//i. Well ; working with force in field ; not seen.
15//z. Well ; blotch not quite dried.
16//?, 19//1, and 24//?. Well.

Case XY. George Xestine. (Muskingum family).
June 6. Inoculated with fungi of rye straw.

Wi. Working, well ; blotch 4 lines in diameter ; red lines radiating from
the wound ; eyes vascular.

12//?. Well; working with field force; not seen.
15//?. Well; blotch dried.
16//?, 19//?, and 24//?. Well

Case XYI. James Galvin. (Muskingum family.)
June 6. Inoculated with fungi of rye straw.

9//?. Blotch looks well ; 4 lines in diameter ; red lines radiating from
the wound.

1 2//?. Well ; working with field force ; not seen.
15//?. Blotch dried ; has cough and coryza.

16//?.. Has cough and coryza; slightly sick ; in bed for 24 hours; no
blotches.

19//?.. Well. Has had no blotches. Was well and out working with
the force on the ITth.
24//?. Well.

1862.] Salisbury, Inoculation with Straw Fungi.

391

Case XYII. John Boyd. (Muskingum family.)
June 6. Inoculated with fangi of rye straw.

Wi. Blotch looks well ; size of a three cent piece ; red lines radiating
from the wound ; eyes vascular.

\2th. TVell ; working with the force ; not seen.

\bth and l^th. Has cough and coryza ; fever; headache; lassitude;
slightly sick; no eruption. Was in bed 1|- day,

l^th and 2ith. Has been well since the ITth, working with the field
force.

Case XYHI. George Harmis. (Muskingum family.)
June 6. Inoculated with fungi of rye straw.

^th. Blotch 4 lines in diameter ; red lines radiating from the wound ;
eyes vascular.

nth. Well; blotch dried.

mh, mh, im, and 2m. Well.

Case XIX. Edward Smith. (Muskingum family.)
June 6. Inoculated with fungi of rye straw.

Wi. Blotch 3 lines in diameter ; red lines radiating from the wound.
\Wi. Well; working with field force; not seen.
mh. Well ; blotch dried.
im, mil, and 2m. Well.

Case XX. Jacob Myres. (Muskingum family.)
June 6. Inoculated with fungi of rye straw.
Wi and 12th. Well ; working with field force ; not seen.
Ibth. Well ; blotch dried.

l^th. Headache ; some fever ; cough and coryza ; in bed for 1 day ; no
eruption.

19r/i and 2ith. Has been well and working with the force since June
lYth. Has had no eruption.

Case XXI. Wm. Dayton. (Muskingum family.)
June 6. Inoculated with fangi of rye straw.

Wi. Blotch looking well : 3 lines in diameter ; red lines radiating from
the wound ; eyes vascular.

12th. Well; working with field force; not seen.
mh. Well ; blotch dried.

mh, Idth, and 24:th. Has been well since the 15th. Xo signs of measles.

Case XXII. Charles Ryan. (Muskingum family.)
June 6. Inoculated with rye straw fungi.
" Blotch small ; slight red lines radiating from wound.

12th. Well; blotch dried.

loth and IQth. Coughing and coryza ; with pains in head.

12th. Broke out with what was supposed to be measles; eruption was
not carefully examined; was not much sick; this is a scrofulous subject
and has sore eyes.

24:th. Well; and working with force.

Case XXIII. Milan G-oldsboro. (Muskingum family.)
June 6. Inoculated with fungi of rye straw.

dth. Blotch three lines in diameter; red lines radiating from the wound;
eyes vascular.

392

Salisbury, Inoculation with Straw Fungi.

[Oct

mil. Well; blotch dried.

l&h, Idth, and Well; no symptoms of measles yet.

Case XXIY. Beaumont Byers. (Muskingum family.)
June 6. Inoculated with the fungi of rye straw.

dth. Blotch four lines in diameter; looks well; red lines radiating from
the wound; eyes vascular.

12;^/i. Well; blotch dried.

IQth, and 12th. Well; working with field force; not seen.

2Ath. Eruption first noticed on face, breast, and arms June 21st. June
24th, eruption declined, leaving obscure blue blotches over whole body;
eyes red; some cough and coryza; sickness slight.

Case XXY. Wm. Hancock. (Muskingum family.)
June 6. Inoculated with fungi of rye straw.

dth. Blotch looks well; three lines in diameter; red lines radiating from
the wound; eyes vascular.
12^/z. Well; blotch dried.
15//i and Well; working with field force.

19f/L Eruption appeared first on the ITth on the face; 18th and 19th
broke out on body ; eruption is in patches ; but slightly sick.
24:th. Well; working with field force.

Case XX YI. Yinton Kyder. (Muskingum family.)
June 6. Inoculated with fungi of rye straw,

2th. Working well; blotch three lines in diameter; red lines radiating
from the wound.

12//?. Y^ell; working with field force; not seen.
Ibth and Uth. Well; blotch dried.

19//i and 2#/z. Well; working with field force; no symptoms of measles
yet.

Case XXYII. John Tully.
June 9. Inoculated with fungi of rye straw.
12th. Well; working with field force; not seen.
15th. Well; blotch dried.

IQih, Idth, and 24.th. AYell; no signs of measles yet.

Yisited the institution again with Dr. Effinger July 22d. The measles
had all disappeared some ten days previously. About fifty cases of the dis-
ease had occurred in the establishment since June 24th, but none of them
among the twenty-seven boys that were inoculated. They had all been well,
though constantly exposed to the contagion. The red lines radiating from
the inoculating wounds could not be well seen without the aid of an eye-
glass.

June 9th, three days after the inoculation. Dr. Boerstler and myself saw
the cases and inoculated another boy. Xone had symptoms of measles.

June 12th, Drs. EflSnger and Boerstler saw the cases and made the report
of that date.

June 15th, Dr. Effinger saw the cases and reported their condition. One
of the boys, James Hill, was broken out and in bed. The eruption first
made its appearance upon the night of the 12th of June. Dr. Effinger

1862.]

Salisbury, Inoculation with Straw Fungi.

393

did not notice the case very particularly ; he only observed that he was
broken out, and not very sick.

June 16th, I saw the cases. None of those who had been inoculated
were broken out, except James Hill, noticed by Dr. Ef&nger on the 15th.
The blotches, which had not yet disappeared from his face, were about
one line in diameter, circular in form, and scattered in patches over the
whole body. The individual blotches were about one-half an inch apart.
There was no odour whatever to the disease. The eruption made its ap-
pearance first in irregular patches, on the arms; next on the face; then on
the legs and thighs; and lastly, on the breast. The blotches were small,
circular, and in patches over the whole body; sickness slight.

I do not look upon this case as one of genuine measles ; it may have
been the disease, modified by the inoculation. This can only be settled by
further experience in similar experiments.

June 19th, Dr. EfBnger saw the cases and made the report of that date.
Two more cases, Charles Ryan and Wm. Hancock, were broken out. Wm.
Hancock broke out on the 11th on his face, and on the 18th and 19th on
the body; eruption in patches. Charles Ryan broke out on the 18th and
19th. He is scrofulous, and has chronic sore eyes.

June 24th, Dr. Effinger saw the cases and reported one more boy, Beau-
mont Byers, down with what appeared to be measles. June 21st, the erup-
tion was first noticed on face, breast, and arms. On the 24th it had declined,
leaving obscure blue blotches over the whole body. Some cough and coryza,
and eyes red.

Several of the boys (as will be seen by reference to the notes) who
were inoculated, were affected, between the appearance of the eruption on
James Hill and that on Beaumont Byers, with headache, cough, coryza, and
lassitude, so that they took to their beds for from one to two days; but
there was no eruption, and but slight fever. The four cases where eruption
occurred appeared to be modified types of the disease.

The institution being some seven miles from town, and no physician on
the ground, the cases where eruption occurred could not be studied suffi-
ciently in detail, so as to determine whether they presented marked peculi-
arities in type, to indicate the degree that the inoculation had modified the
disease.

It is through the efforts and kindness of my learned friends Drs. Boerst-
ler and EfBnger, of Lancaster, Ohio, that I am able to present so fine a
list of cases, all occurring under such favourable circumstances, for testing
the virtues of straw fungi as a prophylactic in measles. I am under obli-
gations to them for their interest, zeal, and valuable labours in these
experiments.

Dr. Boerstler reports the following, which he received at the Ohio State
Medical meeting at White Sulphur Springs, June, 1862, from his friend,
Dr. Gordon, of Georgetown, Brown County, 0. "Dr. Gordon has visited

394

Salisbury, Inoculation with Straw Fungi.

[Oct.

ninety military camps, and states that rubeola originated and existed in
every instance where the soldiers slept upon damp straw ; and so far as he
knew, not a solitary case of rubeola occurred in any camp where the soldiers
did not sleep upon straw."

In the year 184t, rust attacked the wheat crop quite generally through-
out Central Ohio. Mrs. J. J. Brasee, of Lancaster, Ohio, states that one
Henry Bowers worked as a farm hand for her husband, Hon. J. T. Brasee,
during that year ; and that during wheat harvest, he (Bowers) was affected
with sore throat, cough, sore eyes, headache, high fever, red face and a
feeling of weariness and depression. Upon Mrs, Brasee asking him what
was the matter, he (Bowers) stated that he had been working in the wheat
field, harvesting ; and that his sickness was produced by the rust on the
wheat. That others working with him were affected in the same way.

The following interesting letter is from Dr. Boerstler.

Lancaster, June 10, 1862.
Dr. Salisbury — Dear Sir: In compliance with your request, I make
the following statement: In my native county of Washington, Maryland,
the hay and grain harvest usually lasts from four to six weeks, and attracts
from the mountain regions a thousand labourers. During the harvest of
1828 or 1829, the year I do not distinctly remember, we had rust in a num-
ber of wheat fields, and amongst the harvesters in those fields, the measles
appeared. The occurrence of measles in midsummer is very unusual, unless
the contagion has been transmitted from early spring. We had, previous
to harvest, no measles in the county, and no cause could then be assigned.
Since the fungoid theory has been broached, is it not probable that the rust
on the wheat may have produced the disease ? This is a subject of deep
interest, and you have my thanks for your persistent efforts in its prosecu-
tion.

I am, dear sir, respectfully yours,

a. W. BOERSTLER, M. D.

In Berkeley's able work on Cryptogamic Botany, it is stated that in reed
beds (South) where the stems are affected with a rust or fungous growth,
(ustilago Typhoides) the workmen suffer from headaches and other bad
symptoms, in consequence of inhaling the abundant spores. On account
of the peculiar symptoms produced (of a typhoid character), it has re-
ceived the specific name Typhoides. This fungus comes under the group
Coniomyctes. The parasitic rusts and mildews come under the same group.

It is an interesting fact that in those regions where the atmosphere is
dry and rain seldom falls, organic decay and fermentation are tardy and
imperfect, fungi are not produced and lung diseases are unknown, except as
importations. Diseased lungs are quickly restored to health. All meats
are cured by jerking (cutting in strips and drying) ; and dead bodies be-
come soon dry and mummified, without being affected with decomposition.

I am engaged in some experiments which will soon be ready for the press,
connected with fermentation, decay, and fungoid development, which throw
interesting light upon this matter.

1862.] IS'oRRis, Opium Poisoning treated by Belladonna. 395

Art. TV. — Cases of Opium Poisoning treated by Belladonna, ivith Re-
marhs. By William F. Norris, M. D., Resident Physician to the
Pennsylvania Hospital.

Case I. , aet. 19, druggist, was admitted into the Pennsylvania

Hospital Feb. 21st, 1862. On the morning of the 21st he came to the
shop of his employer as usual, where he remained till after 10 o'clock,
when he went to Rosengarten & Son's chemical works, and there purchased
an ounce of the sulphate of morphia. He then walked into the outskirts
of the city where he obtained some water, poured it into the bottle contain-
ing the morphia, and after having swallowed a large mouthful, recorked
the bottle and put it into his pocket. This bottle was subsequently obtained
by his employer, who carefully evaporated the contents to dryness, and found
seventy-five grains missing from the ounce. The patient insisted that none
of the contents of the bottle had been spilled. He afterwards wandered
about the town for an hour and a half, when he began to feel tired and
sleepy, and being near a friend's house, went in, stating that he had poisoned
himself, and that he wished an interview with his sister before he died. He
now appears to have become frightened at the step he had taken, and a few
minutes after, although he was very sleepy, and his gait staggering, walked
to a neighbouring drug store, and obtained and swallowed two drachms of
tannic acid, with a view of counteracting the effects of the morphia. His
friends being much frightened, at once sent for his employer, who soon
arrived and administered a quantity of sulphate of zinc. Dr. W. F. Atlee,
a short time after, repeated the dose which then caused free emesis. He
also gave a strong decoction of coffee with two grain doses of Squire's ex-
tract of belladonna, in solution, which were repeated at short intervals,
until in about an hour he had taken twenty grains of the extract. When
admitted into the hospital at 2.15 P. M. his pupils were contracted to a
pin's point, his pulse 80 and soft, his gait staggering ; -slow of speech, al-
though if sharply questioned, he would answer his name. He complained
of thirst, and would sleep even when standing up if those supporting him
did not keep him constantly in motion. He was at once sent into the
garden, where two attendants kept him walking briskly. Ten grains of
Herring's extract of belladonna in solution were then administered, and
this was repeated in half an hour (3 o'clock). The pulse had now risen
to 100, but the pupils were still excessively contracted, his intellect was,
however, more active, and he now gave a tolerably clear account of him-
self, complaining of thirst. At 3.30 the pupils were beginning to dilate,
though he continued still very drowsy. At 3.45 his condition remaining
unchanged, the pupils continuing about the same size, and no flush of the
face being perceptible, ten grains more of the extract of belladonna in so-

396 NoRRis, Opium Poisoning treated by Belladonna. [Oct.

lution were given, making in all fifty grains, thirty of which were given
after his entrance into the hospital. At 4.5 there was a marked change for
the worse; he could no longer support his own weight, and the attendants
who had charge of him dragged him along; his pulse was 120, and his
pupils widely dilated. He was now carried up stairs, stripped and put
under a cold shower bath, which revived him so much that he struggled
strongly to get away ; he was rubbed briskly with coarse towels till dry
and the skin red. The good effects of the bath were but transient, for even
before he was thoroughly dried, drowsiness again overtook him, and vigor-
ous shakings with repeated attempts to make him walk entirely failed. He
was therefore placed in bed. His respiration was laboured and very slow.
At this period Dr. F. G. Smith, the attending physician, saw him, and di-
rected the application of the galvanic battery, one pole being placed over the
cervical vertebrae, and the other over the diaphragm. It was then attempted
to cause him to swallow some brandy with two grains of sulphate of
quinia in solution, but this failed, a portion running into the larynx and
exciting cough. Half an ounce of brandy was then given by injection,
and at the same time mustard plasters were applied to the abdomen and
inside of the thighs. Under the action of the battery the frequency of the
respiration was much increased.

At 5.30 the pupils were fully dilated, respiration 11 per minute, pulse
112, capillary circulation more active, and a slight red flush of the face
showed the full action of the belladonna. The injection of brandy was
repeated at 6.30 and 7.30, but there was no material change in the symp-
toms. At 8.30 the pulse was found to be more feeble, the lips bluish, and
respiration more laboured. The temperature of the surface was not much
reduced. The galvanic battery was now reapplied, and under its influence
the number of respirations rose to 13 per minute ; this was followed by an
injection of brandy, and sulphate of quinia. At 9.45 the injection was
repeated ; he then opened his eyes and looked around, but would not answer
when spoken to, and soon relapsed into his comatose condition. His pupils
continued dilated, hnd did not contract under the influence of light. Res-
pirations were 12 to the minute and not quite so stertorous. Pulse 114
and stronger, the skin was warm and the flush had disappeared from the
face. The mustard plasters having acted well had been transferred to the
back and chest, where, having thoroughly reddened the skin, they were now
removed. At 11.30 the skin was warm, lips red, pupils still dilated, and
immovable, breathing stertorous, 10 per minute. The battery was again
reapplied and the number of respirations increased to 12, pulse 108. He
roused up and made some resistance during the application of the battery,
mumbling, "What are you about?" but at once on cessation of the current
dropped off into stertorous slumber. At 1 o'clock A. M. he had so far
recovered that the nurse was unable to give him his injection on account
of his violent resistance ; he refused to take anything unless he could see the

1862.] NoRRis, Opium Poisoning treated by Belladonna. 39t

Doctor's prescription for it. At 2 he was able to talk, and promised to
swallow the medicine which was directed for him. The nurse reports his
having vomited a dark-coloured liquid during the last hour, his pupils are
still dilated and immovable, pulse 114, respiration 12 per minute. Half
an ounce of brandy was now given him by the mouth, and a wine-glass of
milk punch was ordered for him at 3 and 5. His respiration continued
stertorous. At 8 o'clock he was awake and rational, his pupils somewhat
dilated, pulse 114, full and strong, respirations 16 to the minute, easy and
natural. At 9.30 his condition was much the same, his bowels, however,
had been moved, the evacuation being normal in character. He has also
had much bilious vomiting, to relieve which, he took lime-water and milk.
At dinner time he took some beef essence, which he retained, and has had
no vomiting since. His skin was still considerably reddened from the ap-
plication of the mustard. From this period he continued steadily to im-
prove, and on the next day had regained his usual health and appetite.

Case XL J — K — , get. 55, was admitted into the Pennsylvania Hospital
on the 24th of March, 1862. He had two small superficial wounds in the
neck, and a larger one^ at the bend of the left elbow, exposing, but not
wounding, the median cephalic and basilic veins. He was brought into the
house about 5 o'clock P. M., surly, and rather soporose, with a weak pulse.
It was stated that his wounds were the result of an attempt at suicide at
his place of business early in the morning, and that not succeeding in this,
he had at about 9 o'clock swallowed the contents of an ounce phial of lau-
danum. An emetic was at once administered to him, consisting of thirty
grains of sulphate of. zinc with an ounce of the wine of ipecacuanha, fol-
lowed by a small quantity of w^arm water. In about three-quarters of an
hour this produced slight vomiting. At 6 o'clock five grains of the extract
of belladonna in solution were administered. This was repeated at Y
o'clock, at which period no change was remarked in his condition, except
that he had become more sleepy, and could be kept awake only by having
ah attendant constantly to shake and talk to him. An hour later (8 o'clock)
he had become still more sleepy, and the dose of belladonna (five grains)
was repeated, but it was with great difficulty that he could be made to swal-
low it ; he would put it to his lips, and before he had swallowed more than
a few drops, would again fall asleep. At half past 8, his attendants
were unable to keep him awake. At 9, his pulse was very feeble and rapid,
his breathing stertorous, his pupils — as had been the case from the time of
his admission — contracted, but not to a pin's point. Two grains and a
half more of the extract of belladonna were now administered, large mustard
plasters were applied to the front of the chest, and he was subjected to a strong
current of electricity from an electro-magnetic battery, one pole being placed
over the diaphragm, the other on the cervical vertebrae. His pupils had now
become dilated, showing the full action of the belladonna. ]Si otwithstanding

398 NoRRis, Opium Poisoning treated by Belladonna. [Oct.

these remedies, his respiration grew slower ; at 10, the pulse at the wrist could
not be felt (auscultation over the heart, however, showed it to be 120). A
little later, even under the stimulus of the battery, his respirations were only
seven per minute. Artificial respiration was now employed, causing expi-
ration by pressure on the anterior part of the thorax, and allowing inspi-
ration to take place through the natural resiliency of the parts. Small
doses of whiskey, frequently repeated, were administered. It was with
great difficulty, however, that he could be made to swallow it. Under this
treatment he slowly improved; at 2 o'clock A. M. his pulse was 120, and
could easily be felt at the wrist ; respiration still stertorous, sixteen to the
minute. At 4, 8, and 9 o'clock no change was noted, except that his pupils
were less dilated than they had been the night before. At the latter hour,
milk-punch every half hour, with 20 % spts. ammonia) aromat. was ordered.
His condition remained much the same up to 12 o'clock, when he suddenly
sank, and a few minutes after expired. No post-mortem examination could
be obtained.^

The first of the preceding cases presents several points of interest. 1st.
The length of time which intervened between the taking of so large a quan-
tity of morphia, and the appearance of the symptoms, which mark the
second or soporose stage of the action of that drug. 2d. The recovery of
the patient after taking so large a quantity of the poison. 3d. The action
of the belladonna.

I. The length of time which intervened between the taking of the large
dose, and the appearance of the symptoms. — In regard to the first point,
Mr. Taylor, in his work on Poisons, remarks: "When any one of the salts
of morphia is taken at once in an overdose, the symptoms are strongly
marked, and they follow each other more speedily. They generally com-
mence in from five to twenty minutes after the poison has been swallowed.
Although this be the rule, yet the volume of the same author furnishes a
remarkable exception to it, for at page 541, he relates the case of M. Bon-
jean, who swallowed fifty-five grains of the acetate of morphia, dissolved
in an ounce of water, in whom " no symptoms of any importance mani-
fested themselves until an hour after the poison was taken, and then there
was simply giddiness, with a tendency to sleep. Two hours after the
occurrence, he had still the power to answer questions ! In four hours,
deep coma supervened."

Christison quotes a case from Orfila where twenty-two grains of the
muriate of morphia were taken, in which four hours elapsed before the
patient first felt approaching stupor.^ Half an hour later he could still
answer questions, although he could not see the interrogator. This de-

1 I am indebted to my colleague, Dr. John Ashhurst, for the notes of this case,

2 Taylor on Poisons, Philadelphia, 1859, p. 544.

^ Christison on Poisons, Philadelphia, 1845, p. 558.

1862.] NoRRis, Opium Poisoning treated by Belladonna. 399

lajed action is seen in other preparations of opium, and the same author
relates the case of an habitual drunkard, who swallowed two fluidounces of
laudanum, "while intoxicated to excitement from beer and spirits," where
no material stupor appeared for five hours. He also adduces a case taken
from Corvisart's Journal, where two and a half fluidounces of laudanum,
with one drachm of extract of opium (i. e., 213|- grs. of opium) were taken,
without producing well-marked stupor till after the lapse of more than an
hour.

II. The recovery of the patient after so large a dose. — The largest re-
corded dose of any of the salts of morphia from which any patient has
recovered, that I have been able to find, is the case of M. Bonjean (above
quoted) who took fifty-five grains of the acetate of morphia in solution.
Taylor also gives a case where 'fifty grains of the same salt, were taken on
an empty stomach, and another where twenty grains were swallowed, both
of which recovered. Christison (pp. 558-559) mentions an example of
recovery from twenty-two grains of the muriate of the same alkaloid.

III. The action of the belladonna. — Belladonna, under the different
names of c^tpv^vo^ fxavLxo^, solanum furiosum and belladonna, has been de-
scribed by both ancient, mediaeval, and modern writers. As it is an orna-
mental plant, growing in temperate climates, and having berries which
possess a sweetish taste, there have been many cases of poisoning by it
reported, principally from the accidental eating of the berries ; and the
symptoms of poisoning from its use seem to have been almost as familiar
to the old authors as to us of the present day. A knowledge of the an-
tagonistic powers of opium and belladonna seems also to be of early date.
Pena and De Lobel, in their work entitled Stirpium Adversaria Nova,^
so early as 15 TO, give an account of Italian peddlers who excited the
wonder of the common people by giving, to alleviate thirst, portions of the
root of the belladonna, the evil effects of which were averted either by
vinegar, wine, or theriaca.^ In 1661, Horstius, in his Opera Medica,^
relates the case of a man who swallowed a spoonful {cochleare plenum)
of the inspissated juice of the belladonna, by mistake for rhob. sambuci.
This was followed by dimness of vision, dryness of the throat, delirium,
and tremors, from which he is stated to have recovered, after taking

1 Stirpium Adversaria Nova, aiitlioribiis Peteo Pena, et Mathia De Lobel, Me-
dicis. Londini, 1570, p. 103.

2 Tlieriaca was frequently administered by tlie old authors as a specific in all
cases of poisoning ; thus Prosper Alpinus remarks : " Omnes affirmant tlieriacam
illam (viz., Egyptiorum), vim efficacissimam habere adversus omnia venena." —
Prosper Alpinus, De Medicina Egyptiorum, lib. iv. p. 308. Lugdini, Batavorum,
1718. Giacomini also quotes him as stating that opium, combined with belladonna,
weakens the action of the latter.

^ Opera Medica, tom. ii., lib. 10, p. 515. Gouda, 1661.

400 NoRRis, Opium Poisoning treated by Belladonna. [Oct.

tlieriaca, with the juice of rue. In the work of Faber on Strychnomania,^
published in 1617, thirteen cases in which belladonna berries were swal-
lowed, are recorded ; of these, two escaped without any unpleasant symp-
toms, but the remaining eleven were affected with delirium, dimness of
vision, difficulty of swallowing, and a number with redness of the skin.
Out of this number, there were two deaths ; in both the delirium passed
away, and coma preceded death. The treatment in ten of these cases
consisted chiefly of theriaca, with adjuvants, which varied more or less in
each case.^ He also quotes a case from Brotbequius, a contemporary, of
a similar kind, in which recovery took place after the exhibition of
opium. ^ In 1*766, M. Boucher, of Lille,'* published five cases of poisoning
by belladonna berries; his treatment consisted chiefly. in the administra-
tion of emetics, purgatives, enemata, and vinegar ; the latter he looked
upon as an antidote to belladonna. In two cases, however, one of which
was in a state of coma, and the other delirious, preparations of opium
were administered. I have not been able to find any further reference
to the subject until 1810, when Joseph Lipp published an inaugural dis-
sertation, entitled " De veneficio baccis belladonride producto atque opii
in eo usu.^^ This paper I have been unable to consult, but Giacomini,^ in
his Troite de Matiere Medicale et de Therapeutique, states that in it are
recorded several cures by means of Sydenham's laudanum. The latter
author, in his article on opium remarks that it has constantly been
found useful in the treatment of poisoning by hyoscyamus, stramonium,
and belladonna, and asserts " Les Italiens ont donne dans ces cas Vopium
a haute dose et its ont vu la stupeur, le delire et les convulsions dispa-
raitre?''^ In a paper read before the Physiological Society of Edinburgh,
by Dr. Thomas Anderson, in 1854, he remarks that, following out the sug-
gestion of Dr. Graves, that an agent which would dilate- the pupils might
be administered with advantage in cases of coma with contracted pupils, in
low fevers, it occurred to him to use belladonna in opium poisoning, and he
there details two cases successfully treated by it.

From this period up to the present time, there have been num'erous cases
reported in the journals, both of opium poisoning, treated by belladonna,
and belladonna poisoning, treated by opium. Of such of these as I have
been able to collect details, I subjoin the following tabular list.

^ Strychnomania explicans strychni manici antiqiiorum vel solani furiosi re-
centiorum liistorise monumentnm, indolis nocumentum, antidoti documentum, etc.,
by Johannes Matth. Faber, August. M. D. Augustse Vindelicorum, 1677.

2 Ibid., pp. 4-18. 3 Ibid., pp. 25 and 26.

Journal de Medecine, Cliirurgie et Pharmacie, etc., torn. xxiv. Janvier, 1776, pp.
310—332.

5 Giacomini, Traite de Matiere Medicale et de Therapeutique, Paris, 1839, p. 537,
published in the Encyclopedie des Sciences Medicales.

6 Ibid., p. 70.

1862.]

NoRRis, Opium Poisoning treated by Belladonna.
Cases of Opium Poisoning treated by Belladonna.

401

Amount of
opium.

Sol. morpli.
muriatis fgij
(Ed.) (about
grains) iu
36 hours.

Tinct. opii
f5v. (Ed.,)
about 23
4-lOtb grs.
of opium, in
an bour aud

a balf.
Tinct. opii
f gj , i. e. 37i
grains of
opium.

Tinct. opii
f gij, i- e., 75
grains of
opium.

Unknown.

Tinct. opii
fgjss, about
561^ grs. of
opium.

Sydenham's
laudanum
(quantity
unknown.)

.Decoction
containing
two poppy
heads.

The patient previously labour-
ing under delirium tremens,
now fell into profound coma,
breathing 4-5 per minute,
stertorous ; pupils contracted
to mere points ; the pulse ex
cessively weak and slow.

Entirely comatose ; pupils con-
tracted to mere points ; re-
spiration stertorous, 10 per
minute ; the pulse feeble and
extremities rather cold.

Comatose ; respiration sterto-
rous ; pulse feeble, and .50 pei
minute ; surface cold and
pupils contracted to a mere
speck.

State of patient.

Profound coma ; skin pale,
cold, clammy ; pulse feeble,
40 per minute ; respiration
slow and " laborious ; pupils
excessively contracted."

Deeply comatose; pupils con-
tracted "to a pin's head
size."

Somnolence followed by vom-
iting, which was very dis
tressing.

Constant somnolence ; ma-
laise ; nausea ; vomiting ;
face pale ; pulse small ; skin
cool; pupils contracted.

Tinct. opii An hour and a half after tak-
'gij '{i e. 75 ing the opium, she had a
grains of flushed face; pulse 70; con-
opium), tracted pupils ; stertorous
breathing ; could be roused
with great difficulty; was
given an emetic which
brought up dark liquid smell-
ing of laudanum ; 5 hom-s
after taking laudanum was
inseuisible to external im-
pressions ; pupils excessively
contracted ; surface cold and
clammy ; unable to swallow ;
countenance pale; pulse
thready and feeble, almost
imperceptible.

No. LXXXYIII.— Oct. 1862.

Age.

Not

Amount of
belladonna
administered.

Tinct. belladon-
na3 f ."svj ; a dose
of a fluidrachm,
repeated every
half hour.

Tinct. belladon
n£e f .^j-f5ij ; ir
the course of ar
hour.

Extr. belladon-
na3 gr. vij.
Tr. do. fSj.

Tinct. belladon-
nse fgss, as in-
jection per rec-
tum.

Tinct. belladon-
uffi fT560;indose
of lom repeat-
ed every 20
minutes.

Tinct. belladon-
nas f.^xjss; in
less than three
hours.

Hydro-alcoholic
extract of bel-
ladonna two
centigrammes
(about 3-lOths
of a grain.)

One centigram-
me of the hy-
dro-alcoholic
extract of bel-
ladonna (about
16-lOOth gr.)
Tinct. belladon-
nae fsj (by the
mouth) ; Extr.
belladonnse gr.
XX, in solution,
by the rectum
within 171^ hrs.

Results.

Recovered from the
effects of opium but
died 3 days after-
wards from exhaus-
tion on sudden ris-
ing. Coma had dis-
appeared iu i}4 hrs,
after the first dose
of belladonna.

In 5 hours, "all in
dications of opium
poisoning had dis
appeared."

Complete recovery.

Cured.

Perfect recovery in
2 hours.

Ra pid and perfect re-
covery.

The vomiting was
promptly checked,
and all traces of
poisoning disap-

Cure.

In 21 }i hours after
taking the lauda-
num she had en-
tirely recovered.

Authority.

Anderso
Edin. Journ

Med. Sci.,
1S54, p. 377-
378.

Loc. cit.

Mussey.
Bost. Med. &
Surg. Journ.

vol. liv.,
1856, p. 56,
from Cincin-
nati Med.

Obs.
Com^gys,
Ranking's
Abstract,
vol. xxxiii.,
p. 2S0, from
Cincinnati

Lancet.
Lee, Amer.
Journ. Med.
Sci., Jan.
1S62, p. 57-
58.

Motherwell,
Med. Times
and Gazette
Jan, 4, 1S62,
from Austra-
lian Med.
Journ. Oct.,

1861.
B6hier,Ann.
de Th^ra-
peutique,
1860, pp.
18-19, par
A. Bouchar

dat.
Behier, Loc.
cit. p. 19-21.

Duncan,
Am. Journ.
Med. Sci.,
July, 1862,

p. 277-S.

402

NoRRis, Opium Poisoning treated by Belladonna. [Oct.

Amount of
opium.

State of patient.

Age,

Amount of
belladonna
administered.

Results.

Authority.

Tinct. opii
fSj {i. e. i%
grains of
opium.)

Not capable of being roused ;
breathing heavily ; pupils
contracted to a point ; skin
warm ; pulse 100, small ; in-
capable of swallowing. (The
child was convalescing from
an a^ttacli of pneumonia fol-
lowing measles.)

IS drops of Thay-
er's fluid ex-
tract of bella-
donna, in dose
of 2 to 3 drops,
by the rectum.

Died in about 13 lirs.
after taking the
laudanum; asphyx-
iated from the col-
lection of mucus in
the bronchial tubes.
The child had ex-
hibited marked im-
provement after
each dose of bella-
donna, and shortly
before death all
symptoms of opium
poisoning " were en-
tirely relieved."

Blake, Am.
Jo urn. Med.

Sci., July,
1862, p. 280-

281, from
Pacific Med.

and Surg.
Journ., Apr.
1862.

Cases of Belladonna Poisoning treated by Opium.

Interval

since

Amount of

State of Patient.

Age.

taking

Emesis.

Amount of Opium

Result.

Autho-

Belladonna.

Bella-

taken.

rity.

donna.

10 berries.

Dryness of throat,

7 hours

3 hours

Tinct. opii irjjxxxv.

Cured.

Seatou,
Medical

dimness of sight,

to the

after

dose fijlv at first

followed by deli-

first

taking

every 4, then every

Times

rium.

dose of
opium.

berries.

2 hours {i. e. nearly

3 grains of opium; .

and Gaz.
vol. xix.
p. 5ol-2.

8 berries.

Dryness of throat
and tongue, fol-
lowed by deli-
rium.

22hours
to first
dose of
opium.

4 hours
after.

Tinct. opii, frjJxxx,
(nearly 2i grs.), in
dose of iTRx.

Cured,

Loc. cit.

6 berries.

Dryness of throat,
etc., intensely de-

IQi hr's
to first

6J hours
after.

Tinct. opii, f^cxliv,
in dose at first of

Cured.

Loc. cit.

lirious.

dose of

iTRviij, every hour,
afterwards the dose

opium.

was doubled as
morphia. Whole
quantity taken in
151- hours, a little
more than 9 fi^ per
hour.

2 berries.

Delirious, with the
other symptoms
of poisoning.

11 h'rs.

Tinct. opii, Tt^jcxliv,
about 11 grs. of opi-
um in 12 hours.

Cured,

Loc. cit.

12 berries.

Symptoms com-

From a

Tinct. opii, '"Kviij,
and afterwards

Cured.

Loc. cit.

menced in an

dose of

hour, became de-

castor

Ti^xvj, every hour

lirious in 3h hrs.

oil.

till sleep was ob-
tained.

5 berries.

Delirium, etc.

12 h'rs.

Tinct. opii,Tf5clxviij,
about 13 grs. of opi-
um in 17 hours.

Cared.

Loc. cit.

2 berries.

Delirium, etc.

10 h'rs.

None.

Tinct. opii, and mor-
phia the equivalent

Cured.

Loc, cit.

of 24 grains of opi-

um in 38 houi's.

Number of

Delirium, etc.

12 h'rs.

8 hours

Tinct. opii, Tf?lxxvj,

Died 29 hvs.

Loc. cit.

berries

after

6 grains of opium in

after taking

unknown.

taking
berries.

9 hours, dose '"Jviii,
at first, increased
to Wxij.

berries ; co-
matose, and
pupils wide-
ly dilated ;
in all cases
which reco-
vered the
IDupils con-
tracted be-
fore they
slept.

1862.] NoRRis, Opium Poisoning treated by Belladonna, 403

Amount of
BeUadonna.

Siiccus. bel-
ladonna foj.

A cup of the
infusion of
the leaves of
belladonna.

Belladonna
plaster on
the knee; the

cuticle
having been
previously
removed by
a blister.

Belladonna
plaster four
by two on
epigastrium.

State of patient.

Age.

Pupils dilated,
thirsty, skin hot,
pulse 110, these
symptoms which
appeared in 2^
hours, followed
by violent deli-
rium.

Pupils dilated,
tongue dry, pulse
slow and bound-
ing, purple flush
of the face, almost
comatose.

Symptoms analo-
gous to those of
delirium tremens

In less than an
hour bright ery-
thema of the face,
breast, and thighs,
with intolerable
itching, giddi
ness, nausea, di
latation of thepu
pils, constriction
of the fauces, and
thirst.

Headache, giddi-
ness,nausea with-
out vomiting,
dryness of throat,
delirium.

Suppository
containing
one gramme

{i. e. 15A3
grains) of as-
safoetida,
extr. bella-
donna one
centigramme
(i. e. 0.15 gr.)
one had been
administered

every day
for six days,
when symp-
toms of poi-
soning ap-
peared.

Dryness of tongue,
face flushed, eye
injected, pupil
dilated, mind i
little excited.

5 hours
till deli-
rium set

in, 15
hours to
1st dose
of mor-
phia.

Interval
since
taking
bella-
donna.

hour.

28 hours
to the

1st dos
of opi-
um.

Emesis.

None.

Amount of opium
taken.

10 m solution of
muriate of morphia
(L.) (with fSj of
brandy) 15 hours
after eating berries,
then fell asleep, du-
ring sleep a scarlet
rash appeared,
woke the next
morning delirious
and was given the
|d of a grain of
morphia in divided
doses, but did not
sleep till evening;
woke well.

Tinct. opii, gtt. 120.

3 centigrammes
(nearly half a gr.)
of the gummy ex-
tract of opium from
hour to hour.

Tinct. opii, fSj, aq.
cinnamoni f gj,
afterwards Tr. opii
Tipxv. " The first
dose antagonized
the belladonna in
less than :iO minutes
after it was taken

Laudan. Liq. Syd.
gtt. XV, with extr.
opii gr. J in solution
every five minutes
after the first four
doses the delirium
began to yield, dose
repeated now every
half hour only
" On the following
morning the patient
was in a perfectly
satisfactory state,
and despite the ra-
ther large quantity
of opium taken, no
sign whatever of
narcotism was oh-
servable, an unan-
swerable proof of
the antagonism of
these two medi
ciiies."

15 grammes of ' 'sirop
diacode" caused
subsidence of all
the symptoms in 25
minutes. The same
quantity was given
in the evening with
two cups of cofi"ee.

Result.

Cured.

Autho-
rity.

J. Todd,
British
Medical
Journal,
Sept. 21,
1861, p.
305.

Lee, Am.
Journal
Med.ScL,

Jan.,
1862, p.

57.
Cazin,
Traite
prat, des
Plantes
Medicin.
Paris,
1858, p.

125.
Lopez,
N. Am.
Medical

Chir.
Eeview,
1 March,
1860, p.
285.

Perroud,

Bank-
ing's Ab-
stract,
vol. 33,
1861, p.
280.

B^hier,
Ann. de

Th6-
rapeu-

tique,
p. 22-21,
1860, par
A. Bou-
chardat.

404 NoRRis, Opium Poisoning treated by Belladonna. [Oct.

Cases of Poisoning by Atropia treated by Opium.

Amouut of
atropia
iniected.

State of patient.

Age.

Amount of opium or its
preparations adminis-
tered.

Kefiult.

Authority.

Sulpliate of
atropia, gr.
injected
over the
sciatic
nerve.

Sulphate of
atropia, gr.
l-12th.

Sulphate of
atropia, gr.
l-30th.

Face flushed, breathing hur-
ried, pulse rapid and small,
skin hot and perspiring, rest-
less, hands moving as if en-
gaged in his ordinary work,
inability to speak from dry-
ness of the mouth, itching of
the skin, both corneaj were
disorganized (previously),
and therefore pupils not vi-
sible.

Dryness of throat, pulse rapid
and rather small, slight de-
lirium, subsultus, and jerk-
ing of the hands.

Face intensely red, eyes bi'il-
liant, irides dilated, mouth
and throat dry, difficulty of
swallowing, nausea.

Toxic effects in half an hour,
face and eyes injected, pu-
pils dilated, giddiness and
staggering gait, gastric pains
but no vomiting.

Morphise muriatis solut.
TTJxxv. (double ordinary
strength of the Edin-
burgh Pharmacopoeia) i.
e. about X gr. of the mu-
riate of morphia, were
injected into the gluteal!
region of the opposite
limb.

Moi-phi£8 muriatis solut.
■"5xv. (same strength
as above) i. e. about X
of a grain.

"3^ grain doses of mor-
phia were given in quick
succession, and in ano-
ther hour the man was
out of bed and well, ex-
cept the mydriasis which
remained until the fol-
lowing day."

)4 grain doses of morphia
"promptly allayed the
symptoms."

Almost im-
mediately
became
calmer,
slept in an
hour; next

day was
quite well.

Eelief im-
mediate.

Cured.

B. Bell.
Edin. Med.
Journ., vol.
iv., July,
1858, p. 5-6.

Ibid. p. 6-7.

Lee.

Lee.i

In addition to the cases detailed in the foregoing table I have met with
several others which, however, have not been reported with sufficient accu-
racy to. admit of being tabulated. Thus, M-. Behier gives seven cases of
poisoning resulting from subcutaneous injections of the sulphate of atropia ;
he records one of these at some length, and sums up his remarks as regards
treatment thus: ''In him, as in six other cases, opium in form either of
extract or syrup arrested all the toxic phenomena." (Ann. de Theropeuti-
que, 1860, p. 38.)

M. CouRTY, also, treating of the use of the same alkaloid in hypodermic
injections, remarks: "jN'evertheless, in the small number of cases where the
atropic intoxication has given origin to cerebral symptoms which have
appeared to require treatment, opium in doses of 25 milligrammes (i. e.
0.28 grain) every half hour hastened the return of the functions to their
normal state, by neutralizing in a manner the effects of belladonna upon
the brain. One to two pills has ordinarily sufficed for a cure." (Ann. de
TMrapeutique, par A. Bouchardat, 1860, p. 40.)

In addition to the cases referred to in the foregoing table, where opium
and belladonna have been given with a belief in their antidotal powers,
several interesting observations are recorded where these agents in large
quantity have been administered simultaneously through accident. Chris-
tison relates the case of a lady poisoned by three successive injections into

' I am indebted to my colleague, Dr. C. C. Lee, for the details of these cases. He
refers to th'em in his paper on Opium and the Mydriatics. — Amer. Journ. Med. Sci.,
.Jan. 18G2, p. 59.

1862.]

NoRRis, Opium Poisoning treated by Belladonna.

405

the vagina, each containing ''the active matter of a scruple of opium and
half an ounce of belladonna leaves." Three hours afterwards she was
insensible and motionless, the face pale, pupils dilated, pulse frequent and
small, and the breathing hurried. He remarks: "Here the opium seems to
have prevented the delirium usually induced by belladonna in the early
stage, while on the other hand the belladonna prevented the usual effect of
opium upon the pupils, and actually produced the opposite action."^ The
patient entirely recovered. Cazin gives an instance where six grammes of
Sydenham's laudanum with two grammes of tinct. belladonnse (equiva-
lent to vini opii f5j, rrj^xlv; tr. belladonna f5j, IT. S. P.) with forty
grammes of the oil of sweet almonds, intended as a liniment, were by mis-
take swallowed. This large dose caused only somnolence, injection of the
face and conjunctiva, and dilatation of the pupils.^ Dr. Coale reports a case
where a child aged nine years swallowed two suppositories containing four
grains of extract of belladonna and four grains of opium with very slight
effect. The reporter, however, ''supposes it possible" in this case that as
dinner had been eaten a short time before, this may have retarded absorp-
tion.-^ Newman records a case where minute portions of a belladonna plas-
ter accidentally swallowed immediately dispelled the soporific effects of a
previous dose of morphia and caused some of the symptoms of belladonna
poisoning.*

The foregoing cases seem conclusively to show that in opium poisoning,
belladonna in doses which in a state of health would certainly poison, may
be administered with impunity and be followed by a rapid subsidence of the
symptoms produced by the exhibition of the former drug, and vice versa
that opium rapidly and safely counteracts the poisonous influence of bella-
donna. The treatment above indicated has,, indeed, in some cases failed,
and this may prove that they are not mutually specifics; but even in these
fatal cases (which are few) we may sometimes see a partial amelioration of
the symptoms, and it is well worthy of inquiry how much in these instances
the relative quantities of the two drugs administered, the stage of poison-
ing in which the patient was first seen, the age and constitution may have
contributed to the result.

Finally, how do they counteract each other ? The mode of action of
these drugs on the nervous system is not at present well understood, although
several able essays have been written upon it. To those interested in the
toxicology of these prominent narcotics I would especially refer as well
worthy of perusal the papers of Mr. Hughes On the Significance of the
Contraction and Dilatation of the Pupil produced by Opium and Bella-

' Christison on Poisons. Philada., 1845, p. 742.

2 Cazin, Plantes Medicinales Indigenes. Paris, 1858, p. 149.

^ Coale, Amer. Journ. Med. Sci., vol. xxvi. 1853, p. 69.

^ British Med. Journ., Julj 13, 1861, p. 30.

406

AsHHURST, Fracture of the Sternum.

[Oct.

donna respectively;^ Mr. Harley On the Physiological action of Atropine
in Dilating the Pupil of Fuller On the Administration of Belladonna,
and on certain Causes which modify its action;^ and of Lee On Op)iuni
and the Mydriatics^

The further investigation of these subjects offers an attractive field for
future observers as well as to experimental physiologists. The object of
this paper will have been fully attained if it succeeds in drawing more
attention to the subject by exhibiting the mass of evidence which has already
accumulated to sanction a belief in the mutual antagonism between opium
and belladonna.

Art. Y. — On Frstcture of the Sternum. By John Ashhurst, Jr., M. D.,
late Senior Resident Surgeon to Pennsylvania Hospital.

Patrick G , a labouring man aged thirty-seven years, was admitted

into my ward in the Pennsylvania Hospital on the 26th of December, 1861,
with the following curious complication of injuries : His sternum was
fairly broken across a little below the junction of the manubrium and
gladiolus ; his left clavicle was broken very obliquely at the outer third,
and the sternal end luxated from its attachments, and riding down over
the first rib and broken sternum ; in addition to these injuries his left
radius was obliquely fractured in its lower third.

The accident had happened in this way : the man was riding in front of
one of the small hand-cars used by workmen upon railways, and by a sud-
den jolt had been thrown forwards between the wheels and beneath the
axle of the car, which passing over him crushed his breast against the
ground.

The shock at the time of admission was considerable ; the dyspnoea very
great, and accompanied by constant coughing and spitting of blood.
Great anxiety and a firm expectation of death tended to complicate what
under the most favourable circumstances would have been a case of very
doubtful prognosis.

The displacement of the sternum was inwards, so as to press upon and
probably wound the lung, the upper fragment being depressed ; the frac-
tured clavicle allowed the shoulder to fall very much forward ; while the
deformity in the radius was eminently characteristic.

The various injuries were dressed in the following manner : Compresses
were placed over both portions of the sternum (so as to relieve the angular
inward displacement), over the luxated sternal end of the clavicle and over
the seat of fracture in the same bone, and were secured in their places by
broad strips of adhesive plaster, and a bandage as firmly applied as could

» London Med. Rev., August, 1860.

2 Edin. Med. Journ., vol. ii. part 1, 1857, pp. 431-435.

3 Proc. Royal Med. and Chir. Soc, vol. xlii., 1859, pp. 289-308.
Am. Journ. Med. Sci., Jan. 1862, pp. 54-60.

1862.]

AsHHURST, Fracture of the Sternum.

407

be borne by the patient. Fox's apparatus was applied for the fractured
clavicle, and the radius was dressed in the manner usual in this hospital,
yiz., in a Bond's splint with compresses above and below.

The clavicle apparatus had to be removed in a few hours, as it was
found to increase the dyspnoea. An anodyne and expectorant mixture
was prescribed, and in the evening carbonate of ammonia in doses of five
grains was ordered to be administered every two hours.

The extreme difficulty of breathing (thirty respirations being taken in
the minute), the very weak and rapid pulse (120 beats to the minute), and
the presence of a cold clammy sweat over the face, made the prognosis
very unfavourable, and it appeared extremely improbable that the poor
fellow would live through the night.

In the morning, however, he was more easy, the dyspnoea less, and the
amount of blood in his expectoration slightly diminished ; he was still in
a very precarious situation, but continued daily to amend, till, on the 2d
of January, 1862, he was able to bear the reap plication of the apparatus
to the clavicle. He was at this time supported by a bed-chair ; his carbonate
of ammonia was diminished, and a strong, but easily digested diet per-
mitted. In a week more he was able to breathe comfortably in a supine
position, and the carbonate of ammonia was entirely dispensed with.

As would be expected from the above history, union of the clavicle took
place with marked deformity. For the first week, it must be remembered,
no apparatus at all could be borne, and orthopnoea prohibited the supine
position. When, on the eighth day, the apparatus was reapplied, it had
to be left so loose as to be of only comparative utility, and it was not until
the third week, by which time union was pretty firm, that treatment capa-
ble of maintaining proper apposition of the fragments could be employed.
After the fourth week dressings to the radius were omitted, and on January
29th, all apparatus was removed, the arm being merely supported in a
sling.

The sternum was united without any perceptible deformity, the disloca-
tion of the sternal end of the clavicle was very much reduced, and the cure
might be pronounced under the circumstances very good. He was dis-
charged on the 13th February, having been in the house exactly seven
weeks. He subsequently reported himself to me on the 11th of April,
1862, having acquired considerable use of his arm but not able to raise
the elbow above the level of the shoulder.

Fractures of the sternum are generally the result of direct violence and
of a very powerful force ; instances are not wanting, however, in which
this bone has been broken by counter-stroke or even by muscular action.
As to the cases recorded as happening by counter-stroke ov " contre-coup,^^
it is somewhat questionable whether they were really fractures, or whether
they might not more properly be designated as luxations. That there
exists a true joint in the junction of " the first and second pieces of the
sternum, is declared by Maisonneuve to be the fact in an average of three
cases out of five ; while the co-ossification of manubrium with gladiolus he
regards as absolutely anomalous. (Maisonneuve, Luxations du Steimwn,
in Archives Generales de Medecine, Juillet, 1842.)

"The junction of the first sternal bone with the second," says Beclard,

408 AsHHURST, Fracture of the Stenmm. [Oct.

"does not occur until near sixty years, sometimes much later, or even
never." {Journal de Medecine, 1820, t. i. p. 17.)

I greatly doubt if the proportion of cases in which a true joint (that is
with double articular cartilages) occurs, be so great as Maisonneuve asserts ;
for I find no mention of such a condition in the books of anatomy, nor in
fact in any other author ; but under any circumstances it would seem more
probable that a dislocation or a diastasis should result from a fall on the
back, communicating the force to the sternum indirectly, than th^t the bony
fibres themselves should be torn apart. And in very few of the reported
cases, have either the symptoms during life, or the post-mortem appear-
ances rendered it certain that a fracture existed rather than a dislocation.

The first case, which is always referred to as an instance of fracture by
counter-stroke, is that narrated by David (occasionally quoted under the
pseudonym of Bazille), in his prize dissertation before the Royal Academy
of Surgery of Paris ; this was the case of a man who fell some fifty feet,
breaking the spinous processes of two vertebrae, the left thigh, and caus-
ing, in the author's words, "the separation of the first bone of the sternum
from the second." (David, Prize Dissertation, etc., translated by Justa-
mond, p. 137.) This was, therefore, by the reporter's own statement, a
diastasis, not properly a fracture, although spoken of by the author as
such, and frequently quoted as such by later authorities.

Sabatier's second case, which he refers to the effect of counter-stroke, was
clearly a true fracture ; for not only was crepitus present during life, but
an autopsy confirmed the diagnosis (llemoire sur la fracture du Ster-
num; Mem. de V Institut., t. ii. an. vii. p. 120 et seq.) ; but the fact of
counter-stroke is not very clearly established, unless the circumstance of the
mnn being found lying on his back after twelve hours, be proof that he
originally fell in that position. The matter is still further complicated by
the patient's having received several violent blows with the fist before being
thrown into the trench in which he was found.

RoUand's case, however, quoted by Malgaigne from the Bulletin de
Tiler apeutique, t. vi. p. 288, would appear to leave no room for doubt ;
in this case, the patient struck her back against a projecting body, and
received a fracture through the middle bone of the sternum. {Treatise on
Fractures, Packard's edition, p. 365.)

Cassan relates a case in which a man jumping from a third story win-
dow, fell on his feet, and afterwards on his back, sustaining a transverse
fracture of the sternum. {Gas Bares, Archives de Medecine, Jan. 1827,
p. 82.) The whole case, however, is so briefly reported (occupying in all
less than half a page), that it can hardly be decided positively in which
category it should more properly be placed.

In the case which occurred at St. George's Hospital, in 1832 {Med.-Chi-
rurg. Remew, Oct. 1832, p. 536), resulting from a fall on the head, the
'" fracture" is said to have been " about opposite the cartilage of the third

1862.]

AsHHURST, Fracture of the Sternum.

409

rib." With this exception, however, the whole description of the case so
perfectly answers to Maisonneuve's account of luxation (Archives de ^lede-
cine, Juillet, 1842, pp. 249-280), that I should be rather inclined to place
it in the latter class. Two other cases, quoted by Malgaigne, I have not
been able to refer to, and hence am not prepared to say whether they were
fractures, or merely dislocations.

Auran gives a case almost identical with that reported by David, and
which he very properly designates as a diastasis. It was the case of a
mason who fell on his back, fracturing the spinous processes of two ver-
tebrae, breaking also his thigh, and producing a separation of the two upper
bones of the sternum. Union took place in twelve days, and the man re-
covered. {Journal de lledecine, par M. A. Koux, tome xxxvi. p. 520.)
The same author also gives a case where separation of the first and second
bones occurred from a violent effort at lifting made with the shoulder, which
the patient had placed under a bar, which he was using as a lever of the
second order. An abscess over the seat of injury followed, caries ensued,
and the trephine was twice used, with ultimate complete recovery. (Op.
citat., p. 531.)

A very interesting case of fracture of the sternum from muscular action
is reported by Drs. Lucchetti and Posta, in the Bulletino delle Scienze
Mediche di Bologna, for April, 185t, in which the accident occurred dur-
ing labour ; here crepitus was pathognomonic of the real existence of frac-
ture, and a cure ensued at the end of thirty-five days. Another case is
referred to by the same gentleman, in which death resulted on the fourteenth
day, but it is not stated whether an autopsy confirmed the diagnosis. {Am.
Journ. Med. Sci., July, 1858, p. 2t2.) Two more oases of the same kind
are given by Chaussier {Revue Medicale, 1827, tome iv. p. 260), andDubos
gives a very curious case, in which a juggler, leaning backwards, and try-
ing to lift a great weight with his hands and teeth, felt his breast-bone sud-
denly give way. {Maladies du Sternum, Paris, 1835.) In these three cases
the fracture took place above the articulation. Still another case is re-
ported in which the bone was fractured in its upper third from contraction
of the diaphragm in vomiting. {Gazette des Hopitaux, March 20, 1830.)

I have been particular in ascertaining, when the means within my reach
enabled me to do so, whether fracture really existed in the cases reported
as from indirect violence, or whether the injury could not more properly be
regarded as diastasis ; for upon this we may found an important principle
for forming our prognosis.

Luxation or diastasis is comparatively a slight injury, for the posterior
ligament remaining intact, as was found in all the cases examined by Mais-
sonneuve {op. citat., p. 269, etc.), the viscera escape laceration, and there-
fore if there be not some complication which proves fatal, the patient may
be expected to recover.

Fracture, on the other hand, is very likely to be accompanied with seri.

410

Ash HURST, Fracture of the Sternum.

[Oct.

ous lesion of lungs or heart ; in three instances the heart itself was torn,
while in others the pericardium only has been injured. (Hamilton, quoted
from JSf. Y. Journ. of Med., Treatise on Fractures and Dislocations, p.
171.) Emphysema and heemoptysis not unfrequently accompany fracture,
and are always alarming symptoms. Dupuytren records a case of fractured
sternum, in which the lesion was at the junction of the middle and lower
thirds ; the upper fragment was much depressed, and after death was found
to have pierced the pericardium, and gone through two-thirds of the thick-
ness of the wall of the right ventricle. Several ribs were also broken, and
marked emphysema was observed. {Legons Orales, t. i. pp. 120 and 123.)

Now I believe the majority of supposed fractures, resulting from coun-
ter-stroke and muscular violence, are nothing more than diastases ; and
hence, even if the swelling should be so great as to prevent our recognizing
the condition of things by local examination, the history of the case may
often enable us to form a prognosis, which we could not safely do in any
other way.

Malgaigne declares that fractures from direct violence never occur, except
in the middle piece of the sternum ; hence a blow on the manubrium would
cause a diastasis merely, and therefore an accident of v»^hich the results
would probably be favourable, as in the case recorded by Auran. {Journal
de Medecine, par M. A. Roux, tome xxxvi. p. 521.)

Even in fractures where no injury is done to the thoracic viscera, abscess
of the mediastinal space is apt to take place, and proves a very serious
complication ; this occurred in both of Chaussier's cases, and in that in
which vomiting was the cause of fracture. That equally serious conse-
quences may follow luxation, or that they may even occur without any
injury to the bony parietes of the chest is true ; but such cases are rare.
Lonsdale's case of ruptured trachea, without external injury, is an example
of this kind {Treatise on Fractures, p. 239), and similar cases are re-
corded by Gosselin and Alfred Poland {Holmes'' System of Surgery, vol.
ii. p. 386), while as lately as last January, my friend and former colleague,
Dr. Charles C. Lee, reported to the Pathological Society of Philadelphia a
very interesting case in which rupture of the left lung took place without
either fracture or wound of the thoracic walls {Am. Journ. Med. Sci.,
April, 1862, pp. 419-421). These, however, are among the curiosities of
surgical practice, and, as a rule, if the patient has escaped fracture in an
injury to the $ternum, a favourable result may be anticipated.

Fractured Sternum, under any circumstances, is a very rare accident.
But two cases occurred at the Middlesex Hospital in six years, and at the
Hotel-Dieu only one in eleven years. Hamilton does not refer to a single
case as occurring under his own observation, for the case in which he
speaks of the ensiform cartilage being ''broken in," was evidently a bend-
ing of the cartilage, and not a true fracture. {Op. ciiat., p. 110.) Schenk-

1862.]

AsHHURST, Fracture of the Sternum.

411

ins quotes from Bauliinus a similar case, in whicli, however, the deformity
was congenital. {Ohserv., Lib. XL p. 322, Frankfort, 1609.)

Prof. G-ross records a case occurring in the practice of Dr. Kohrer, of
this city, in which the fracture was in the upper part of the bone, and was
produced, according to Prof. Gross, by muscular action, though the de-
scription would place it, with equal propriety, under the head of counter-
stroke. "A distinct grating noise," it is said, was heard when the man
coughed." This is the only case referred to by Dr. Gross, as having come
under his own observation. (System of Surge-ry, vol ii. p. 167.)

In the record of the Pennsylvania Hospital for the last ten years, I find
but two cases previous to my own. The first was that of a labouring man,
aged twenty-one, who was admitted on the 28th April, 1856. The frac-
ture, it is stated, was at the junction of the first and second bones, a par-
tial fracture, with a depression of nearly half an inch, and no injury to the
soft parts. ^sTo apparatus was employed, and the patient left the house by
his own request, on the eleventh day, with the deformity ttnredaced. The
injury was produced by a box weighing 800 lbs. sliding upon him, and rest-
ing upon the back of his neck. From the fact of this case being reported
as a partial fracture, I te.ke it for granted there was no crepitus ; from the
position, the absence of crepitus, the cause (indirect violence acting by
counter-stroke), and the absence of any complication whatever, I have no
doubt this was really an example of diastasis.

In the second case, the fracture was near the middle of the sternum, with
no injury to the soft parts around the seat of fracture. This patient was
also a labouring man, aged twenty-one, who entered the house on August
16th, 1858, having fallen from the height of three stories, striking his loins
on a sand heap. The fracture was transverse, and the upper fragment de-
pressed a quarter of an inch ; it was treated by means of adhesive strips,
completely surrounding the thorax, the patient being kept in a recumbent
posture, and he was discharged cured on the thirtieth day. This was a
very rare case, the fracture being in the middle of the bone, and yet pro-
duced by indirect violence.

, I am very kindly permitted by my former colleague, Dr. Lee, to refer to
a case which has recently occurred in his ward, and which he reported to
th'e Philadelphia Pathological Society on the 25th of June, 1862. In this
case, which was complicated by fracture of the humerus, and of several
costal cartilages of the same side, the separation took place immediately
below the junction of the fii'st and secon-d pieces. The lower fragment was
bevelled from above downwards, and from behind forwards, and the upper
fragment correspondingly in an opposite direction. The patient was an old
man who had fallen from a considerable height through an open hatchway,
and was picked up after several hours, and brought to the hospital in a'
dying condition. In this case emphysema was very well marked, and the

412

AsHHURST, Fracture of the Sternum.

[Oct

man expiring shortly after his admission, an autopsy, at which I was pre-
sent, revealed the fracture as described above.

The following may be regarded as almost positive evidences of the exist-
ence of fracture, viz., the presence of crepitus, the situation of the injury
being below the junction of the first and second bones, or the fact of the
upper overlapping the lower portion. In diastasis, the lower fragment
almost always rises in front of the upper, as it is drawn up by the action
of the ribs in breathing, while the upper having lost its attachments, re-
mains fixed. In some cases the swelling may be so great as to prevent cre-
pitus being perceived, even if it were present; the depression may be in the
upper fragment ; and the seat of injury may be so near the junction of the
first and second bones, as to cause a doubt as to the true condition. Now,
if the injury have resulted from direct violence, we can tell at once whether
it be a fracture or dislocation, from the history ; if the force has been ex-
erted on the upper bone, it is a dislocation, for fracture from direct violence
never occurs in that part ; if, on the other hand, the force has been exerted
on the middle bone, we may safely assume it to be a fracture, for disloca-
tion has seldom, if ever, resulted from such a cause.

In a case where the injury is from indirect violence, the diagnosis is not
so certain ; the prima* facie probability is in favour of dislocation, and if
there be no haemoptysis, emphysema, or other visceral complication, we
would be still more inclined to this view ; but should an opposite state of
things exist, we might properly consider it to be a true fracture.

The prognosis of diastasis if uncomplicated by other injuries is favoura-
ble; that of fracture much more doubtful.

The treatment of fractured sternum as regards the bone itself is simple
enough ; we should endeavour to reduce the deformity, and keep the parts
at rest by bandages, adhesive strips, or any other plan that may suggest
itself. The constitutional treatment as laid down in the books is actively
antiphlogistic ; that there are cases in which bleeding may be not only
justifiable but absolutely necessary, of course I shall not pretend to deny ;
but I am very sure that in the case of my patient such a course would have
been followed by serious, if not fatal consequences, and I firmly believe that
his life was saved by the unsparing use of carbonate of ammonia.

Yarious plans have been proposed for elevating the depressed bone : re-
duction can generally be effected by pressing on the ribs, bending the spine
over a cushion or bolster, or by similar methods ; but in some cases all
these plans fail. French surgeons have suggested cutting down and intro-
ducing elevators, trephining, the use of a blunt hook, etc. ; but even if
these methods should succeed in removing the displacement, it would be
far from certain that the deformity would not return ; and the harm re-
sulting from the conversion of a simple into a compound fracture would
be very considerable. I should be governed by the same rules as in a frac-
ture of the skull with depression ; if there were already an external opening,

1862.] Salisbury, Poisoning with the Vegetable Alkaloids. 413

I should remove any loose fragments, and endeavour by appropriate means
to restore the parts depressed to their natural position : but in the case of
a simple fracture I should hesitate very much before resorting to any such
heroic mode of practice.

^^'or should we trephine even if an abscess of the mediastinal space
should occur ; for if the abscess were merely behind the sternum, the symp-
toms would be too obscure to justify the operation ; and if it were more
extended, it would point between the ribs at one or the other side, and
might be opened with almost no risk to the patient. That the mediastinal
space can be cut into without injury to the pleura is shown by many cases,
among others by one which came under my own observation. (Am. Journ.
Med. Sci. for Jan., 1862, p. 64.)

Professor Gibson, formerly of the University of Pennsylvania, has
several times trephined for abscess beneath the sternum, but concludes his
remarks on the subject in the following words: ''Experience, however,
has taught me latterly that the operation of the trephine just referred to
is seldom productive of lasting benefit. In patients upon whom I have
operated I have found the caries to return, and eventually death has taken
place — apparently from phthisis pulmonalis." (Inst, and Fr act. of Sur-
gery, vol. i. p. 253.)

Malgaigne records one case each of longitudinal and of splintered frac-
ture ; the latter from his own observation, the former quoted from Barrau.
Ploucquet quotes two cases of longitudinal fracture, one from Kraemer and
one from Meyer, in which it is stated that the injury resulted from pressure,
(ex pressione corporis), and that union did not take place. (Ploucquet,
Literatura Med. Digesta, vol. iv. p. 81.) .

I have said nothing about fracture of the ensiform cartilage, because,
though spoken of by Gibson and other systematic writers, I can find no
instance of it on record. Hamilton's case already referred to does not
seem to have been properly a fracture.
• Philadelphia, July 26, 1862.

Art. YI. — Some Experiments on Poisoning with the Vegetable
Alkaloids. By J. H. Salisbury, M. D.

Of the detailed action of the vegetable alkaloids, either in medicinal or
poisonous doses, upon the animal system, we know too little. There is
enough, however, known to warrant the statement, that there is no class
of bodies destined to occupy a more important place in our materia medica,
and none through which (when properly administered) we can more readily
influence diseased conditions — functional or organic.

414 Salisbury, Poisoning with the Vegetable Alkaloids. [Oct.

One interesting action of aconite, as developed by these experiments, is
the peculiar persistent tonic contraction it produces in the muscular fibres,
thereby tending to empty all open cavities of the body. Another is its
influence in producing paralysis of the nerves of sensation and motion.

Yeratria is remarkable for preserving the animal heat, the arterial con-
dition and great fluidity of the blood, and for producing symptoms some-
what resembling those of hydrophobia.

Picrotoxin and hyoscyamus produce a peculiar kind of spasmodic mus-
cular motion, &c.

Reserving further comments for a future occasion, we offer the following
examinations as a part of a series of experiments in which we have for
several years been engaged. We hope some features in them may interest
others to enter carefully upon similar inquiries.

I. Poisoned a Gat with Tincture of Aconite. — On the 2'rth of March,
Y A. M., administered to a small cat (one which was somewhat debilitated
from a previous small dose of aconite) six drops of what is called by
homoeopathists the mother tincture of aconite. In administering it I opened
the cat's mouth, held her head back, and poured the six drops directly into
the throat. The whole was swallowed.

th. 10m. Commenced swallowing as if there was something in the
throat.

1h. 15m. Commenced vomiting. Vomiting continued at intervals for
twenty-five minutes. Internal muscular spasms and contractions severe ;
breathing laboured ; eyes fixed and glassy ; pupils dilated.

th. 40m. Vomiting ceased. During vomiting there was considerable
vertigo and dimness of sight, which increased till vomiting ceased, when
there was so much exhaustion that the cat was unable to stand. She fell
down upon her side ; her head drawn back ; limbs all extended, and toes
drawn in. She lay in this position, having an occasional spasm, till
death, which took place at 8 o'clock and 30 minutes, precisely one and a
half hour after the poison was administered. When dead her head was
drawn back; limbs all extended; mouth closed firmly; eyes open, glassy;
pupils somewhat dilated ; toes drawn up towards soles of the feet ; some
frothing at the mouth, and the whole muscular system in a state of tonic
contraction.

Post-mortem seven and a half hours after death. — assisted by Dr. Swin-
buriie. — There was a general tonic muscular contraction, producing unusual
rigidity. Jugulars full; mesenteric veins full; intestines shortened in length
and decreased in diameter.

Stomach contracted to about one-third its normal size ; mucous mem-
brane drawn into folds or rugge. Folds mostly longitudinal towards the
upper curvature ; more zig-zag towards the lower curvature. Contents a
small quantity of mucus, tinged with blood and bile. Mucous coat very
much congested; of a brownish-red colour; some spots deeper than others.

Duodenum contracted in length and diameter ; considerable congestion
of mucous membrane; but less than in the stomach. Contents, small quan-
tity of mucus adhering to the mucous membrane, slightly tinged with blood.

Jejunum contracted both in length and diameter. Mucous membrane
considerably congested.

Ileum contracted both in length and diameter. Mucous membrane

1862.] Salisbury, Poisoning with the Vegetable Alkaloids. 415

slightly congested, and towards the upper portion covered with mucus,
slightly tinged with blood. The lower portion contained a small quantity
of fecal matter, mixed with something resembling bile.

The caecum and upper portion of the colon contained considerable fecal
matter, which was thin and watery. The lower portion of the colon and
the rectum were filled with fecal matter much more hard and dry. The
walls of intestines thick and rigid. The whole length contracted ; but the
small intestines more than the large. The stomach, duodenum, and jeju-
num were drawn into folds, or corrugated ; the two latter but slightly.

Bladder very much contracted ; walls thick. Had the appearance of a
hard, round ball ; entirely empty.

No congestion of brain; simply fulness of the veins.

Small portion of lungs were slightly congested, especially those portions
which came in contact with the diaphragm.

Liver slightly congested in those portions which came in contact with
diaphragm and stomach. Gall-bladder nearly empty.

Veins generally full.

When the cat was vomiting, most of the time she was standing, leaning
against the side of the room, seemingly unconscious ; eyes fixed and glassy,
and pupils somewhat dilated.

Peculiar symptoms previous to death. — Spasms in throat and swallow-
ing ; general muscular rigidity; frothing at mouth ; severe internal spasms ;
and vomiting of mucus, frothy matter, and food, almost without intermis-
sion. Extension of all the limbs; head drawn back; eyes fixed and glassy;
toes drawn in towards soles of feet ; general paralysis of nerves of sensation
and motion ; vertigo, and a death-like stupor.

Peculiar post-mortem appearances. — General muscular rigidity; jaws
firmly closed ; stomach contracted to about one-third its normal size ; in-
testines shortened in length and diameter diminished. Mucous membrane
of stomach highly corrugated or drawn into folds. Effusion of blood into
stomach and small intestines. Mucous membrane of stomach and small
intestines highly congested. A rigid tonic muscular contraction of bladder.
Gall-bladder partially emptied, and general fluidity of blood.

II. Effects of Tincture of Aconite on the Human System in Poisonous
Doses. — In the fall of 1852 I attended Miss J., aged 19 years, during an
attack of meningitis. She possessed a vigorous constitution, and had always,
up to the period of this attack, enjoyed excellent health. After recovery she
was affected with severe neuralgic pains in the head and limbs, with some
sHght paralysis of the sphincters and bladder. For these I was giving tinc-
ture of aconite with decided benefit, in connection with other medicine. The
preparation of aconite used was a solution of five drops of the tincture (pre-
pared according to the formula in the U. S. Dispensatory) to one hundred
drops of water. Ten drops of this solution was the prescribed dose. This was
to be taken every hour through the day. I had cautioned her particularly
against taking a larger dose. One afternoon, during a call of some lady friends,
she thoughtlessly drank from the bottle about four drachms of the solution,
which would be equal to twelve drops of the tincture. This dose was taken
about 5J o'clock P. M. At 6 o'clock, half an hour after, I was called to
see her. Arrived at six o'clock and ten minutes. Found her seated in an
arm chair, held there by her mother. She was unable to speak. All the
muscles of the body were in a state of rigid tonic contraction. She was

416 Salisbury, PoisoniDg with the Vegetable Alkaloids. [Oct.

scarcely able to move a limb, and when motion was effected it seemed diffi-
cult to control it. The whole muscular system affected with slight spas-
modic twitches, which apparently kept time with the pulse. Pulse small,
spasmodic, and irregular; cold, clammy sweat over whole surface of body;
hands clenched; jaws firmly closed, unable to speak; eyelids nearly closed;
eyes fixed and glassy. A death-like weight and griping constriction in
stomach and bowels. Felt as if she was dying, and as if everything inside
would be forced out — as she described it after recovery. JN'erves of sensa-
tion and motion quite paralyzed. Breathing laboured ; a feeling of suffo-
cation. Knew what was passing around her; but could not speak. Hack-
ing and swallowing at times. Remained in this condition between two and
three hours. Under the apphcation of stimulants and friction she gradually
recovered, so that on the following morning she felt quite well, with the
exception of a ''death-like feeling of tightness," as she described it, at the
"pit of the stomach." This passed away in the course of two or three
days. Although great danger attended this over-dose of aconite, yet it had
a salutary effect upon the disease.

Enumeration of Peculiar Symptoms. — Tonic muscular conti'action over
whole body; jaws fixed, unable to speak ; hands clenched; muscular twitch-
ings, which keep time with the pulse ; breathing laboured ; a feeling of
suffocation, and a death-like weight and griping constriction at pit of sto-
mach. Conscious of what was passing around her ; but unable to speak
or tell her wants. Cold, clammy sweaty over whole body. !N"o vomiting,
yet felt as if everything inside would be forced out. Almost complete para-
lysis of nerves of sensation and motion. Spasms in throat, which gave rise
to hacking and swallowing at times.

III. Poisoned a Large Male Cat ivith Tincture of Aconite. — June 8,
1853, 10 o'clock 5 minutes A. M. Administered to a large healthy male
cat, full grown, twelve drops of tincture of aconite. Grave it by setting him
upon his hips, securing legs, holding head back, and pouring the tincture
directly into the throat.

lOh. 1m. Commenced swallowing as if something was in the throat.

lOh. 8m. Vomited about half drachm of frothy matter and food ; then
commenced frothing at the mouth and swallowing, which continued till 10
o'clock and 19 minutes.

lOh. 19m. Vomited about half drachm of white frothy mucus; after
which continued to froth at the mouth and swallowed till 10 o'clock 21
minutes,

lOh. 21m. Vomited about half drachm of white frothy mucus, mixed with
traces of food. Remained in one position from 10 o'clock 7 minutes to
] 0 o'clock 22 minutes.

lOh. 22m. Vomited slightly, and turned partly around.

lOh. 24m. Vomited. Considerable vertigo ; staggered in walking. Pu-
pils dilated; scarcely notices anything about him. Nerves of sensation and
motion quite paralyzed.

lOh. 25m. Vomited. Spasms in vomiting more severe than at first.
Made a moaning noise.

lOh. 2Tm. Vomited about quarter drachm of mucus. Losing control of
limbs. Strength rapidily declining. Cannot stand without leaning against
tlie wall. Breathing begins to be laboured and difficult. Swallowing less
frequent. Frothing less.

lOh. 3tm. Nearly ceased frothing and swallowing ; breathing very

1862.] Salisbury, Poisoning with the Vegetable Alkaloids. 411

laboured, short, and irregular. Pulse small, corded and irregular. Eyes
fixed and glassy.

lOh. 50in. A disposition to raise himself up and stand on hind legs.
Yomited slightly ; occasional internal muscular spasms. Lying on the
right side, quite exhausted.

llh. Severe internal muscular spasms as in vomiting, but nothing
vomited.

llh. 5m. Same as last. llh. 10m. Same. llh. 15m. Same,
llh. 27m. Same as last. Breathing very difficult and irregular,
llh. 35m. Lying on side, apparently in great pain, moaning at every
breath. Breathing very short and laboured. Pulse scarcely perceptible.
] Ih. 45m. Several internal spasms.

llh. 50m. Lying on right side, breathing short and laboured. Eyes
very much sunken. Unable to move. Pulse scarcely perceptible. Eyes
fixed, rolled back, and glassy.

12h. 8m. P. M. Severe internal spasms. Frothing commenced again at
the mouth.

12h. 25m. Moaning, and lying on side. Begins to move his head.
Breathing slightly easier. Eyes still fixed and glassy. Pupils dilated and
quite insensible to light.

Ih. 15m. Gave him five drops more. So much irritation about throat
and fauces that spasms were produced preventing swallowing when tincture
was poured into throat.

Ih. 35m. Gave six drops more.

2h. Gave four drops more.

2h. 13ra. Yomited mucus slightly.

2h. 25m. Yomiting; moaning. Fell upon side exhausted. Breathing
laboured, short, and irregular.

2h. 30m. Severe internal muscular spasms as if in vomiting.

7h. 30m. About 3 P. M. sank into a stupid state, in which he has con-
tinued till a short time before death. At intervals moaned pitifully ;
occasional feeble internal spasms.

Died at 43 minutes past 7 P. M., nine hours and thirty-eight minutes
after first dose was administered.

Post-mortem 47 minutes after death.

Veins. — Jugulars full ; mesenteric veins full. Yense cav^ less full than
the jugulars and other small veins.

• Stomach about one-third its natural size. Yery much corrugated from
muscular contraction. Walls thick and rigid. Mucous membrane highly
congested, has a dark reddish pink colour. Some portions darker than
others. Stomach empty with the exception of a small quantity of frothy
mucus, tinged with blood adhering to inner coat.

Duodenum much contracted in length and diameter. Slightly corru-
gated. Empty with the exception of a small quantity of frothy mucus,
tinged with blood, adhering to mucous membrane. Mucous surface highly
congested and of a dark reddish pink colour.

Jejunum contracted in length and diameter ; considerable congestion
but less than in the duodenum. Empty with the exception of a small
quantity of mucus tinged with blood.

Ileum contracted like jejunum ; congestion slightly less than in the jeju-
num. Contents, small quantity of mucus tinged with blood — less than in
jejunum.

Caecum, colon and rectum somewhat contracted ; considerable conges-
No. LXXXYIIL— Oct. 1862. 27

418 Salisbury, Poisoning with the Yegetable Alkaloids. [Oct.

tion in patches, in CEecum and upper part of colon. Kectum natural ; colon
contained a small quantity of fecal matter, thin and watery. Rectum full
of fecal matter, in the upper portion soft and in the lower portion drier
and more firm. -

Gall-bladder partially empty ; contents black, tarry, thick and viscid.

Liver slightly congested in those portions in contact with stomach and
diaphragm. Portal veins full.

Lungs natural, with the exception of those portions in immediate con-
tact with the diaphragm.

Heart contained a small quantity of fluid blood, and a little fragment of
clot in the right ventricle. In other parts of body, blood dark and fluid.
Left ventricle empty.

JSTo congestion of bram, simply venous fulness.

Bladder contained about half a drachm of urine ; walls firmly contracted
upon their contents ; thick and rigid.

Intestines. — Whole leyigth of intestinal canal four feet four inches.
Length of intestines of a cat about the same size poisoned with belladonna,
five feet five inches. Length of intestines of one poisoned with stramonium
(about same sized cat) five feet ten inches.

Pecidiar symptoms before death. — Swallowing and spasms in throat ;
frothing at mouth ; paralysis of nerves of sensation and motion ; almost
constant spasms in the region of the stomach and diaphragm, accompanied
by vomiting. Eyes fixed and glassy; pupils dilated; vertigo; breathing
laboured ; pulse small and irregular, apparently unconscious of surround-
ing objects ; takes no notice when called ; muscular contraction of a tonic
character.

Enumeration of pecidiar post-mortem appearances. — General mus-
cular rigidity, jaws closed, stomach and intestines very much contracted;
mucous membrane of stomach very much corrugated and congested; blood
effused into stomach and small intestines, blood fluid; rigid muscular con-
traction of bladder. Gall-bladder partly empty.

lY. Poisoned a Female Dog with Tincture of Aconite. Administered
per Anum.

June 18, 1853, 11 o'clock 5 minutes A. M. Administered three drachms
of tincture of aconite (TJ. S. P.) per anum to a dog above the medium size,
which had eaten nothing since 6 P. M. yesterday,

llh. Tm. Severe tenesmus of rectum and bladder; passed urine and slight
quantity of fecal matter.

llh. 10m. Constant tenesmus of rectum and bladder, passed small quan-
tity of fecal matter. Eyes dull and heavy.

1 Ih. 15m. Constant tenesmus. Passed about half drachm of fecal matter.
Eyes dull and heavy, llh. 25m. Same.

llh. 29m. Commenced panting with mouth open, constantly in position
to discharge bowels. Constant straining.

llh. 31m. LTneasy, moving around.

llh. 32m. Commenced drooling, constant tenesmus.

llh. 38m. Yomited slightly about half drachm of frothy mucus. Froth-
ing at mouth. Slight muscular spasms in hind part of body, drawing legs
up towards abdomen. Panting and drooling.

llh. 42m. Stiffness and partial paralysis of nerves of sensation and mo-
tion in- posterior parts of body; severe and constant tenesmus.

llh. 45m. Passed small quantity of thin watery fecal matter, vertigo

1862.] Salisbury, Poisoning with the Yegetable Alkaloids. 419
#

increasing rapidly. Hardly able to walk without falling. Constant pant-
ing and droohngs. Eyes glassy, pupils dilated. Vision indistinct.

11 h. 48m. Fell upon side, where she lay three minutes, got up, whirled
around a few times. Constant straining with slight passage from bowels
and bladder.

llh. 50m. Vomited a small quantity of frothy mucus. Tenesmus severe
and constant. Passed about two drachms of soft fecal matter, mixed with
mucus. Frothing at mouth continued. Vertigo increases, uneasy. Stag-
gering about, lying down, then getting up and attempting to walk. Stupid.
Partial paralysis of nerves of sensation and motion.

12h. Tenesmus constant and severe. Passed about half ounce of thin,
watery, slimy, fecal matter. Limbs quite stiff and rigid.

12h. 5m. P. M. Discharge of thin watery fecal matter, mostly water,
about one ounce.

12h. 20m. Slightly easier. Some short intermissions in tenesmus. Less
vertigo.

12h. 22m. Administered two drachms more of tincture of aconite per
anum.

12h. 24m. Slight passage of urine, also passed nearly all the tincture
administered at 12 o'clock 22 minutes.

12h. 50m. Apparently in considerable pain. Lying on side. Slight
passage from bowels of watery fecal matter. Tenesmus becoming inter-
mittent. It has been constant up to this time.

Ih. Gave an injection of four drachms more of tincture. Rectum
appears to be perfectly paralyzed; so much so that the injection of four
drachms has no apparent effect upon it. Walked olf and laid down on side ;
where she remained quiet till 1 o'clock and 30 minutes.

Ih. 30m. Breathing becoming difficult. Eyes glassy and pupils dilated.
Occasionally raising up one foot.

Ih. 43m. Vomiting with severe spasms and a loud choking noise, with
frothing at the mouth. Extreme vertigo.

Ih. 50m. Lying on side. Breathing spasmodic, pupils much dilated and
insensible to light.

Ih. 56m. Scratching her head with her fore foot. Strangling and choking.

2h. Lying on side. Spasms in posterior part of body. Spasmodic
twitching of muscles generally. Breathing difficult. Lolling; unable to
stand. Pulsations irregular.

■ 2h. 46m. Raised herself on her feet, then settled down upon her abdo-
men and held her head up.

2h. 52m. Gave two drachms more by injection per anum.

3h. 31m. Lying on side. Heart beats slow, full, and irregular.

3h. 25m. Howled. Severe spasms of muscles of respiration, which lasted
about one minute. This was followed by a large passage of watery fecal
matter.

3h. 27m. Respiration ceased in a severe general convulsion. Heart
ceased beating about one minute after.

There is less general muscular rigidity in this case than either of the
others. This may possibly be owing to the fact, that infusion of tobacco
was given to her about twelve hours before I administered to her the first
injection of aconite. The first dose (three drachms), if it had not been
partially discharged by the constant straining, would no doubt have pro-

420 Salisbury, Poisoning with tlie Vegetable Alkaloids. [Oct.

duced death in a short time after it was administered. The second dose of
two drachms, administered at twelve o'clock and twenty-two minutes, was
mostly discharged two minutes after. When the four drachms were given
at one o'clock P. M., the lower bowels had become torpid or paralyzed,
hence the poison was not discharged, nor did it produce any decided effect
upon the system until its influence had reached the upper portion of the
intestines and stomach. Yery severe vomiting and choking commenced
forty-three minutes after the four drachms were administered. At two
o'clock fifty-two minutes P. M., gave two drachms more. In thirty-three
minutes afterwards, this was passed with fecal matter, which was probably
brought down from the upper portion of the bowels by the severe muscular
spasms produced by the previous dose.

Peculiar symptoms. — Constant tenesmus of bladder and rectum from
three minutes after the injection was made till one hour and forty-five min-
utes after, when it became intermittent.

Vomiting commenced thirty-three minutes after the first dose was given.
Frothing at the mouth commenced at the same time. Paralysis commenced
in the posterior parts of the body and advanced towards the head. The
other symptoms similar to symptoms in the case when aconite was admin-
istered per orem.

Post-mortem 4 hours and 33 minutes after death. — Whole intestinal
canal shortened and diminished in diameter. Rectum so much contracted
that it would have been difficult to have introduced a goose-quill; walls
thick and rigid; entirely empty, save a thin coating of mucus tinged with
blood. High state of congestion. The contraction and congestion dimi-
nished in the direction of the stomach. The whole intestinal canal, how-
ever, was highly congested and entirely empty, except a thin coating
and a small quantity of fecal matter, thin and watery, in the lower portion
of jejunum.

The stomach was very much contracted, walls thickened, and mucous
membrane drawii into folds and highly congested ; entirely empty. Saw a
small quantity of mucus adhering to mucous membrane. Bladder entirely
empty and drawn into a hard round ball. Slight congestion in the portion
of lungs next to diaphragm. /

V. Poisoned a Female Dog icitli Tincture of Aconite. June 11, 1853,
3 o'clock 38 minutes P. M. Admiiiistered to a dog aged about 4 years,
and weighing 15^ pounds, sixty drops of tincture of aconite; strength, two
parts of root to four parts of alcohol. Do not know how long before
taking the poison the dog had eaten food.

3h. 4m. Commenced swallowing, and opening and shutting the mouth
and licking lips with tongue.

3h. 42m. Vomited about three ounces of frothy white matter mixed with
undigested food. Passed water.

3h. 43m. Vomited about one ounce of greenish frothy matter mixed with
food. Eyes glassy and somewhat fixed.

3h. 44m. Vomited about one-half ounce of white frothy mucus.

5h. 45m. Vomited about one drachm of greenish-white frothy mucus.

3h. 46m. Vomited about one drachm of greenish-white frothy mucus.

1362.] Salisbury, Poisoning with the Vegetable Alkaloids. 421

3h. 47m. Yomited about one drachm of greenish-white frothy mucus.
Frothing at mouth. Passed water. Breathing laboured.

3h. 50m. Severe internal spasms or efforts to vomit. Breathing difficult.
Lying on abdomen groaning, head up. Made an effort to get up, and
finally succeeded, but could not stand without reeling.

3h. 55m. Fell on side. Severe internal spasms. Great difficulty in
breathing. Moaning. Pupils dilated. Yision indistinct. Losing control
of limJos.

4h. Endeavoured to get up, but fell back on side. Heart beats irre-
gularly. Respiration difficult and irregular. Severe internal spasms of
muscles of stomach and diaphragm. Wagging tail. Limbs stiff, rigid,
and extended,

4h. 3m. Raised on her feet; tried to walk, but fell over.

4h. 5m. Raised again on feet, but fell on side, attempting to walk. Pu-
pils dilated. Eyes glassy and fixed. Takes no notice when called, or of
surrounding objects. Severe internal spasms. Great muscular rigidity.

4h. 10m. Slight frothing at the mouth. Raised on feet and attempted
to walk, but fell over. Quite lost use of limbs. Muscles rigid.

4h. 13m. Lying on side. Breathing slightly easier.

4h. 15m. Breathing slow and irregular; from six to eight respirations
per minute. Wagging tail. Muscles rigid, but less so than at four o'clock
and ten minutes.

4h. 20m. Had eleven respirations during the last two minutes, then
ceased to breathe for three minutes.

4h. 23m. Commenced breathing again. Had eight respirations and then
an intermission. This was followed by great muscular rigidity.

4h. 25m. Commenced breathing again. Breathing heavy and difficult.
Attempted to raise herself on fore feet. Severe internal spasms, and effort
to vomit.

4h. 28m. Succeeded in raising herself on her feet, but soon fell on her
side. Severe internal spasms, and breathing irregular and difficult.

4h. 35m. Severe internal spasms. Lying on side.

4h. 38m. and 4h. 40m. Severe internal spasms and efforts to vomit.

4h. 55m. Administered fifteen drops more of tincture of aconite.

4h. 57m. Mouth open. Standing on feet and making an effort to walk.
Severe internal spasms. Fell upon side. Pupils dilated. Ceased breathing
for two minutes and then drew one breath.

• 5h. Ceased breathing. Heart ceased beating. Eyes open and glassy.
Death occurred one hour and twenty-two minutes after the first dose was
administered.

Peculiar symptoms before death. — Swallowing, and opening and shut-
ting mouth. Licking lips. Tonic muscular rigidity. Limbs extended.
Severe internal spasms almost constant, attended with severe efforts to
vomit. Passage of urine. Eyes fixed and glassy; pupils dilated. Froth-
ing at mouth. Severe spasms of muscles of respiration. General paralysis
of nerves of sensation and motion. Respiration irregular and laboured.

Post-mortem June i2th, 16 Jiours and 20 minutes after death. — Con-
siderable tonic muscular rigidity. General venous fulness ; jugulars dis-
tended with blood ; mesenteric veins distended with blood. Blood dark
and unusually fluid.

Bladder empty; contracted to a hard, round ball.

Small intestines six feet six inches long. Large intestines twelve inches
long.

422 Salisbury, Poisoning with fhe Vegetable Alkaloids. [Oct.

Stomach YBYj much contracted, about one-third its usual size; mucous
membrane very much corrugated, highly congested, and covered with a
small quantity of frothy mucus tinged with blood, which was the only con-
tents of the stomach.

The duodenum was much contracted, both in length and diameter; mu-
cous membrane highly congested, with some spots more highly reddened
than others, and covered with a coating of mucus tinged with blood and
bile.

The jejunum very much contracted in length and diameter, and highly
congested ; the lower portion is less congested than the upper portion, but
equally contracted; contents, mucus adhering to mucous membrane, and
tinged with blood.

The ileum was contracted equally as much as the jejunum, but the mu-
cous membrane is less congested; empty, with the exception of a small
quantity of mucus tinged with blood and bile.

The caecum was filled with fecal matter, thin and watery ; mucous mem-
brane slightly congested.

The colon contained a small quantity of thin, watery fecal matter of a
dark colour; very much contracted; otherwise normal in appearance.

Rectum considerably contracted in length and diameter, and contained a
small quantity of fecal matter, thin and watery, but no perceptible con-
gestion. All the small intestines very much contracted in length and
diameter.

A general fulness of vessels of kidneys.

Slight congestion of lungs in those portions coming in contact with the
diaphragm.

In the liver there was slight congestion, especially in those portions
coming in contact with the stomach and diaphragm.

The gall-bladder was partly filled with a yellowish bile and a black tarry
matter.

The heart was quite empty, except the right auricle; the venae cavae were
only partially full of dark, mostly fluid blood.

The oesophagus was white and pearly, except near the cardiac orifice of
the stomach, where there was considerable congestion. The mouth and
fauces were quite natural, except a coating of frothy mucus.

Brain. — There was considerable congestion of the membranes of the
brain, and slight congested spots in its substance; slight effusion in ventri-
cles ; sinuses and large veins full.

Post-mortem appearances that are peculiar. — General tonic muscular
rigidity. Jaws stiff and closed. Limbs extended. Head drawn back.
Stomach and intestines highly congested and much contracted, the former
being drawn into folds on the mucous surface. Effusion of blood into
stomach and small intestines; blood mostly fluid and dark coloured. Blad-
der in a state of rigid contraction and empty. Gall-bladder partly empty,
and contents peculiar.

YI. Poisoned a Female Dog with Tincture of Aconite. June 12, 1853.
— Height of dog at shoulders 14| inches ; length from top of skull to base
of tail 1 foot 10 inches; weight 16 pounds; age about 1 year. Healthy
and in good condition.

10 o'clock 15 minutes A . M. Administered to-day sixty drops of tincture
of aconite. Strength, two parts root to four parts of alcohol. The dog
has not taken food since 2 P. M. yesterday.

1862.] Salisbury, Poisoning with the Vegetable Alkaloids. 423

lOh. Itm. Yomited about a half drachm of frothy matter, after which
commenced swallowing and opening and shutting mouth, and licking lips.
Respiration becoming difficult.

lOh. 18m. Vomited about one drachm of white frothy matter, with a
little food. Great difficulty in breathing, so much so that she makes a
barking, wheezing noise every breath. Breathing very slow. Lying upon
side, pawing mouth with fore paws. Severe internal spasms of stomach
and muscles of respiration.

lOh. 23m. Losing use of limbs, so much that she can hardly move
them. Eyes fixed and glassy ; pupils dilated. Has been as yet no froth-
ing at the mouth. General muscular tremor.

lOh. 25m. Pawing her head, and groaning. Respiration about eight
per minute, and difficult. Pulse feeble, and about 120 per minute. Severe
internal spasms. Complete paralysis of nerves of sensation in limbs.
Takes no notice when pins are run into them.

lOh. 30m. Passage of hard fecal matter from bowels. About two pul-
sations per minute. Gasping for breath ; from two to three inhalations
per minute.

lOh. 35m. Breathing ceased. Heart ceased beating. Eyes open and
glassy ; pupils dilated. Death twenty minutes after poison was adminis-
tered.

Post-mortem 24J hours after death. — Whole body quite rigid. Jaw^s set
firmly. Limbs extended and stiff. Jugulars distended. Mesenteric veins
full. Length of small intestine sixty-one inches; length of large intestine
fourteen inches.

Stomach very much contracted, about one-third its usual size ; walls
thick and firm ; mucous membrane very much corrugated ; corrugations
longitudinal mostly towards the upper curvature, towards the lower some-
what zigzag ; highly congested, some spots redder than others, and covered
with mucus tinged with blood ; stomach otherwise empty.

Di(0(:/e??z^?7i contracted in length and diameter; mucous membrane slightly
corrugated and highly congested, and covered" with a frothy mucus reddened
with blood towards the upper portion, and coloured with bile in the lower
part ; otherwise empty.

Jejunum contracted considerably in length and diameter; upper portion
highly congested, lower portion but slightly congested ; mucous membrane
covered with mucus tinged with blood ; no other contents.

The ileum was considerably contracted in length and diameter. The
mucous membrane was slightly congested in spots in the upper portion.
Contents, mucus in the upper portion and a small quantity of fecal matter
and bile in the lower and middle portions.

The csecum was filled with fecal matter.

Colon but slightly contracted ; had a healthy appearance ; contents, small
quantity of thin fecal matter.

The rectum was quite natural in appearance ; partly filled with hardened
feces.

The bladder was very much contracted ; appeared like a round, hard
ball ; entirely empty.
The kidneys natural.

The (Esophagus, fauces, and mouth coated with mucus; otherwise healthy
in appearance.

The liver somewhat congested in those portions coming in contact with
diaphragm and stomach.

42-1 Salisbury, Poisoning with the Vegetable Alkaloids. [Oct.

The gall-bladder was about two-thirds full of a clear gelatinous bile,
mixed with a small quantity of dark tarry matter.

Considerable congestion in those parts of the lungs in contact with dia-
phragm.

Right side of heart filled with clot ; the left side empty, with the excep-
tion of a small fragment of clot. The vense cav83 partly filled with fluid
and clotted blood. Sma^ller veins filled with dark fluid blood.

Membranes of the bi-ain somewhat congested. Slight effusion in ven-
tricles ; otherwise healthy.

YII. Poisoned a Large Female Rat with Tincture of Aconite. — Caught
a large female wharf rat in a wire cage about 8| o'clock P. M. June 13th.
The rat was nine inches in length from tip of nose to base of tail. In
attemping to get out of the cage she rubbed the skin off her nose, so that
there was an abraded surface, that bled slightly, about the size of a half
dime. Upon this abraded surface I commenced dropping the tincture of
aconite at 9 o'clock and 10 minutes P. M. of June 13th. In the course of
fifteen minutes I dropped on tvv^enty-five drops, one-fourth of which ran off.

9h. 25m. Began to grow stupid. Breathing somewhat laboured, ceased
jumping about the cage, slight spasms, pupils slightly dilated.

9h. 45m. Moans and sighs in breathing, breathing irregular. Quite
stupid. Eyelids partially closed.

lOh. Stupid, breathing irregular and difiicult. Slight spasms of muscles
of respiration. Makes a slight sighing noise.

lOh. 12m. Sudden and severe spasms causing her to throw herself
upward against the top of the cage.

lOh. 14m. Fell exhausted. Lying on side, breathing slow, short and
laboured, losing use of limbs, vertigo.

lOh. 18m. Quiet, lying on abdomen, difBcult to arouse her. Lay in this
condition till 10 o'clock and 45m. Commenced panting heavily, very
stupid, eyelids almost closed.

llh. 10m. Violent internal spasms followed by slow irregular breathing ;
occasional feeble and rapid spasmodic twitching of muscles.

llh. 15m. Spasms, breathing more slow and difficult.

llh. 25m. Violent spasms, gasping followed by short and hurried respi-
ration.

12h. Slight spasms, breathing more regular and less difiicult, gaining
strength, just able to stand, left her for the night.

June 14th. th. A. M. Very dull and stupid, eyelids nearly closed,
lying upon chest and abdomen, with head between fore legs, quiet.

8h. 30m. The same as at 7 o'clock.

8h. 35m. Dropped six drops more of tincture of aconite on abraded
surface.

8h. 43m. Breathing becoming more difiicult, attempted to walk, could
not without reeling and falling ; finally fell upon side when she remained
quiet in a nearly comatose state, till 11 o'clock and 45 minutes, wlien she
had a severe, sudden spasm, which threw her violently against the top of
cage and at 11 o'clock and 47 minutes respiration ceased. There was no
vomiting or purging in this case.

Post-mortem 51 minutes after death. — Considerable rigidity of muscu-
lar system. Limbs stiff. Jugulars distended. Mesenteric veins full.
Length'of small intestines 51 inches. Length of large intestines 9 inches.

Stomach, contained about one drachm of partly digested food, apparently

1862.] Salisbury, Poisoning with the Vegetable Alkaloids. 425

parts of a mouse. No congestion or corrugation. Quite natural in ap-
pearance.

Duodenum empty except a small quantity of bile. Healthy.
Jejunum contained a small quantity of fecal matter throughout its whole
length.

Cdecum, colon and rectum all healthy in appearance and partly filled
with fecal matter.
Portal veins full.

Gall-bladder nearly empty, contents black and tarry.

Lungs considerably congested, especially the lower lobes coming in contact
with diaphragm. Surface vessels of the heai^t distended ; both the right
and left auricle and ventricles filled with a tough hard clot. Tense cavse
also co7itained some clot. Blood in smaller vessels dark and fluid.

Brain normal in appearance, except a venous fulness, in membranes and
base of brain. Slight effusion in ventricles.

YIII. Poisoned a Large Male Gat ivith Tincture Nux Vomica. — At
11 o'clock and 30 minutes A. M., June 8, administered to a large male cat
twenty-six drops of tincture nux vomica, usual strength. Administered it by
securing legs, holding head back, opening mouth and pouring the tincture
directly into the throat. Slight internal spasms at 11 o'clock and 33
minutes. Yomited about one quarter drachm of partially digested food.

llh. 35m. Afifected with swallowing, vomited slightly.

llh. 3tm. Yomited a small quantity of food and frothy matter.

llh. 44m. Yomited a small quantity of food and frothy matter and two
minutes after vomited again slightly. Severe spasms of diaphragm and
stomach at intervals.

llh. 55m. Tetanic symptoms begin to appear.

12h. 5 P. M. Commenced breathing very short and rapid, about two
hundred respirations per minute, panting, quite lively, comes when called,
purs when back is stroked.

12h. 25m. Slight tetanic symptoms, respiration easy, about one hun-
dred and fifty per minute. Apparently quite recovered. Administered 25
drops more of tincture.

12h. 57m. Severe tetanic symptoms. Lay in violent convulsions for 1 J
minutes ; this passed off leaving him weak and stupid. Breathing rapid.
Eyes closed, difficult to arouse him.

Ih. 35m. Administered 15 drops more of the tincture.

Ih. Sim. Tetanic symptoms begin to show themselves.

Ih, 38m. Convulsions very severe, lasted two minutes.

Ih. 40m. Panting, breathing laboured, lying on side.

Ih. 55m. Convulsions severe, continued with short intervals till 2 o'clock
and 4 minutes, when breathing ceased.

Post-mortem 1 liour and minutes after 'death.

Bladder moderately full of urine, walls thin and soft; no muscular
rigidity.

(Esojohagus considerably congested, lower portion presented a shrivelled
appearance of mucous membrane.

Stomach quite natural in appearance ; no muscular rigidity, mucous
membrane slightly corrugated ; no congestion ; contents bile and frothy
mucus.

Cat had not eaten since yesterday at 4 P. M. No contraction in duode-

426 Salisbury, Poisoning with the Yegetable Alkaloids. [Oct.

num. Slight congestion of mucous membrane; contained a small quantit}^
of bile and mucus.

Jejunum empty; slight congestion.

Ileum contained a small quantity of fecal matter along its whole length.
Healthy in appearance.

Csecum, colon and rectum filled with fecal matter, healthy. Mesenteric
vessels full ; portal veins full ; jugulars full.

Gall-bladder full.

Lungs slightly congested.

Kight side of heaii full of clot and fluid blood ; left side empty.
General venous fulness in brain. Slight effusion in ventricles, mem-
branes of brain slightly congested.

IX. Poisoned a Large Hale Gat ivith Tincture of Belladonna. — Ad-
ministered sixtv drops of tincture of belladonna at 2 o'clock and 13 minutes
P. M., June id, 1853.

2h. 15m. Commenced frothing at the mouth slightly.

2h. 20m. Frothing at mouth increasing. Swallowing occasionally, quite
uneasy.

2h. 28. Holding his head up and looking up toward the ceiling ; sitting
on hind legs. Had a profuse and seemingly involuntary discharge of urine.
Frothing at mouth ceased ; pupils dilated, anxious to crawl off into some
secluded corner.

2h. 35m. Appears to be blind ; pupils very much dilated, occasionally
carries his head back and casts his eyes up towards the ceiling.

2h. 40m. Vomited about one-half drachm of greenish, yellow, watery
liquid ; in vomiting made a noise as if in pain. Held his head up and
back for about one minute. Pupils much dilated.

2h. 45m. Yomited about ten drachms of matter like the last. Losing
use of limbs. Vertigo, almost constantly, swallowing for the last five
minutes.

3h. 9m. Has been constantly swallowing and walking about for the last
fifteen minutes.

3h. 20m. Vomited slightly a greenish white fluid. Either sitting on his
hind legs looking up or walking about.

3h. 30m. Drov\^sy. Slight twitching in different parts of the body.

3h. 40m. Administered sixty drops more of tincture. He did not swal-
low it all — probably not over forty-five drops. Immediately after this lay
down and fell into a sleep, which lasted till 4 o'clock 35 minutes. Pupils
excessively dilated, breathing rather heavy.

4h. 35m. Administered forty drops more of tincture. At 4 o'clock and
38m. became uneasy, walked about, occasionally mewing; vision indis-
tinct, vertigo. This uneasiness and walking continued till 5 o'clock and
5m. when I administered forfy drops more of tincture.

5h. 7m. Breathing laboured, rattling in bronchias; quite comatose.

5h. 10m. Aroused, very uneasy, mewing, walked about staggering. This
continued till 5 o'clock and 20 minutes, when he sank into- a sound sleep,
breathing heavy, forty-eight inspirations per minute.

5h. 33m. Administered forty drops more of tincture. Two minutes after
sank into a deep sleep. Breathing laboured, fifty-two inspirations per
minute, heart beats ninety to the minute. Pulsations feeble, continued in
this state till 5 o'clock and 58 minutes.

5h. 58m. Involuntarily passed urine. Heart almost ceased beating.

1862.] Salisbury, Poisoning with the Yegetable Alkaloids. 42t

twenty pulsations to the minute, feeble, comatose, continued in this state
till 6 o'clock and 15 minutes, when breathing ceased. Whole muscular
system soft and placid.

Peculiar symptoms. — General laxity of the muscular system. luTolun-
tary discharge of urine. Sitting on hind legs and gazing vacantly upwards.
Peculiar rattling noise in bronchise for most of time. Excessive dilatation
of pupils. Peculiar appearance of matter vomited. Losing use of hind
legs first. Frothing at mouth, ceased about fifteen minutes after the first
dose was administered.

Post-mo7iem 1 hour and 55 minutes after death. — General muscular
flaccidity, general capillary and venous fulness. Whole length of intes-
tines, from pylorus to anus, five feet and five inches. Length of small in-
testines fifty-three inches. Length of large intestines twelve inches. Length
of stomach along the upper curvature eight and a half inches. Length of
stomach along the lower curvature four and a half inches.

Stomach over twice as large as the stomach of the cat poisoned with
aconite. Stomach filled with a white jelly. Mucous membrane slightly
corrugated, almost white, no congestion perceptible, except in two or three
small patches.

Duodenum lax and empty, no contraction or congestion.

Jejunum, mucous membrane mottled with small red spots, resembling
in appearance the first stages of scarlatina.

The ileum the same in appearance as the jejunum. Both the jejunum
and ileum contain traces of fecal matter.

The cdecum, colon, and rectum, healthy in appearance, and filled with
fecal matter.

Liver very much congested.

Gall-bladder filled with dark-coloured bile almost black.

Lungs considerably congested, and filled with blood and frothy matter.

Heart empty.

Kidneys congested, which may explain the excessive secretion of urine.
Mucous membrane of oesophagus pearly white.

Mucous membrane of fauces and mouth covered with a little gelatinous
mucus.

General fulness of vessels of brain, slight effusion in ventricles and con-
gestion in membranes.

X. Poisoned a Large Male Cat luiih Tincture of Stramonium. — Cat
full grown, and in fine healthy condition. Administered sixty drops of
tincture of stramonium to it at 2 o'clock and 14 minutes, June 10, 1853.
Had not eaten since four o'clock yesterday.

2 o'clock 16 minutes P. M. Commenced frothing slightly at the mouth,
and two minutes after commenced sneezing and coughing.

2h. 23m. Yomited slightly a frothy liquid 'of a greenish yellow colour.
Pupils dilating.

2h. 27m. Thrusts tongue out between teeth, and opens and shuts them
upon it. Tongue red and apparently swollen, frothing ceased, anxious to
crawl off in some secluded place; mewing.

2h. 36m. Had a discharge of urine, mewing and uneasy.

2h. 42m. Lying on chest and abdomen, quiet, perfectly conscious of what
is passing. Slight vertigo, staggers when walking.

2h. 50m. Quiet, lying as if asleep, remained in this state till three o'clock,
when he got up and walked around, mewing.

428 Salisbury, Poisoning with the Yegetable Alkaloids. [Oct.

3h. 1m. Lay down with head between fore-paws, as if asleep. Kemained
in this state till 3 o'clock and 11 minutes. Woke up, uneasy, commenced
walking about and mewing, continued in this condition till 3 o'clock and
30 minutes. Quiet and drowsy.

3h. 40m. Gave sixty drops more of tincture, swallowed most of it.
Passed urine involuntarily two minutes after. Pive minutes after walking
stupidly around mewing, considerable vertigo ; pupils dilated.

3h. 50m. Yertigo increases, can hardly walk; uneasy, dimness of sight,
continued in this state till 4 o'clock and 5 minutes, when he became quiet,
lay down and slept, breathing easy. At 4 o'clock and 15 minutes vomited
slightly a small quantity of greenish gelatinous fluid, which aroused him.

4h. 20m. Became uneasy, walking about, mewiDg, running against ob-
jects, blind. At 4 o'clock and 30 minutes became quiet, and fell asleep.

4h. 35m. Administered forty drops more of tincture ; about two minutes
after involuntarily passing urine; became very uneasy, mewing constantly;
quite blind ; cannot walk without falling over from side to side, breathing
laboured. This uneasiness continued till 4 o'clock and 50 minutes, quiet,
apparently sleeping ; pulse slow, heavy and feeble.

5h. Woke up very uneasy ; endeavoured to walk about.

5h. 5m. Administered forty drops more of tincture. Two minutes after
became quite comatose ; breathing laboured. Five minutes after, aroused,
anxious, mewing, unable to stand. Ten minutes after, comatose ; lying
on side ; pupils very much dilated. Fifteen minutes after, moving around
in a circle ; mewing ; sixty inspirations per minute.

5h. 33m. Administered forty drops more of tincture. Two minutes
after, lying on side ; comatose ; breathing laboured ; forty-eight inspira-
tions per minute.

5h. 40m. Still comatose ; legs in constant motion ; the fore and hind
legs on one side move together in same direction ; motion alternate, first
on one side and then on the other.

5h. 55m. Heart beats fifty to the minute ; breathing heavy.

5h. 58m. Heart beats forty per minute ; feeble; comatose.

6h. 1 5m. Comatose ; forty inspirations per minute. Continued in this
state till 6^ o'clock P. M.

6h. 30m. Administered thirty drops more of tincture of stramonium.
After a short struggle, he fell down comatose ; heart beating slow, heavy,
and feeble ; breatlaing heavy and difficult. Continued in this state till T
o'clock and 6 minutes.

1h. 6m. Motion in limbs ceased ; eight minutes after, slight motion,
with an attempt to move limbs. Respiration ceased at 7 o'clock and 50
minutes. No rigidity of muscular system ; whole body limber and flaccid.

Post-mortem 55 minutes after death. — No rigidity of muscles ; limbs
relaxed and limber ; general venous fulness.

Jugulars distended with 'dark blood. Mesenteric veins gorged with
dark blood.

Bladder full ; walls thin and flaccid ; no contraction.

Intestines distended with gas ; presented a knotted appearance. Length
of small intestine, fifty-eight and a half inches ; length of large intestine,
twelve inches.

Stomach from two and a half to three lines larger than the stomach of
cats poisoned by tincture of aconite ; slightly larger than the stomach in
the belladonna case. Mucous membrane healthy ; contents, about two
ounces of a watery frothy mucus.

1862.] Salisbury, Poisoning with the Yegetable Alkaloids. 429

Duodenum filled with gas ; healthy ; contents, small quantity of food
and bile.

Jejunum quite empty ; slightly congested in spots and lines.

Ileum more congested than jejunum, but congested very slightly ; con-
tained small quantity of fecal matter.

Csecum, colon, and rectum filled with fecal matter ; healthy.

Kidneys very much congested, which may explain the excessive discharge
of urine.

Portal veins filled with dark blood.
Gall-bladder filled with dark bile.

Lungs very much congested ; filled with dark blood and frothy mucus.
Heart quite empty ; venee cavse filled with dark blood, which contains
considerable clot.

(Esoplmgus very white and pearly. Pharynx and fauces the same.
Brain slightly congested ; vessels all full ; slight elfasion in ventricles ;
considerably congested in membranes.

XI. Poisoned a Male Gat, about one-tliird groivii, loitli Tincture of
Goniuni Maculatmn. — At 3 o'clock 45 minutes P. M., June 10, 1853, ad-
ministered forty drops of strong tincture of conium maculatum (U. S. P.)
to a healthy male cat about one-third grown.

3h. 58ra. Swallows occasionally, licks his lips, and opens and shuts his
mouth.

^ 4h. 3m. Slight vertigo ; dumpish ; swallowing occasionally.

4h. 13m. Yomited one-fourth drachm of white frothy matter; slight
vertigo.

4h. 25m. Quite easy; walking about room,, reeling slightly; pupils en-
larged.

4h. 40m. Administered thirty drops more of tincture. Two minates
after, commenced frothing slightly at mouth ; vertigo. Five minutes after,
unable to walk but a few steps without falling ; attempted to vomit.

4h. 50m. Unable to stand; lying on side.; occasionally coughs; par-
tially comatose. Three minutes after, aroused him ; immediately vomited
about three drachms of water and white frothy matter ; walks with diffi-
culty ; falls every few steps.

5h. 6m. Fell asleep.

6h. 30m. Has slept most of time since 5 o'clock and 6 minutes ; consi-
derable vertigo in walking.

6h. 38m. Administered fifty drops more of tincture conium maculatum ;
immediately fell into a comatose state ; breathed a few times, and expired
at ,6 o'clock and 40 minutes. Eyes glassy and sunken ; pupils dilated.

Post-mortem 22 minutes after death. — No muscular rigidity. Blood
unusually red, both in veins and arteries ; arteries and veins equally full ;
capillary vessels filled with light, bright, red blood.

Bladder soft and flaccid ; contains about two drachms of urine.

Length of small intestines, forty-one inches ; length of large intestines,
seven inches ; no muscular contraction of either the stomach or intestines.

Stomach filled with a slimy, frothy matter or mucus ; mucous membrane
has a slight pinkish tinge ; no corrugation.

Duodenum contains a small portion of slimy, viscid mucus, mixed with
bile ; slight pinkish tinge in spots ; no contraction.

Jejunum quite empty, save a small quantity of mucus adhering to mu-

430

Salisbury, Poisoning witli the Vegetable Alkaloids.

[Oct.

cous surface; mucous membrane lias a light pinkish tinge in spots and
stripes. Ileum same as jejunum. Caecum, colon, and 7'ectum filled with
fecal matter, and healthy.
Kidneys healthy.

Slight congestion of liver. Gall-bladder filled with tarry, black, viscid
bile.

Pancreas and spleen normal.

Lungs slightly congested towards inferior lobes ; contain frothy mucus
in air cells and bronchial tubes.

Heart empty. Venae cavse full of light-coloured blood, mostly fluid.
(Esophagus healthy.

Pharynx, fauces, and mouth covered with frothy mucus.
Brain and membranes quite normal in appearance, except that their
vessels were full of peculiarly red blood.

XII. Poisoned a Healthy Male Cat with Tincture of Hyoscyamus. —
Height of cat 1 inches. Length 15|- inches, exclusive of tail. Girth back
of shoulders 11 inches. Administered seventy drops of the tincture of
hyoscyamus at 10 bours and 5 minutes A. M. June 12, 1853. Only swal-
lowed about sixty drops.

lOh. 18m. Becoming quiet and stupid, pupils begin to dilate.

lOh. 28m. Beginning to mew. Occasionally swallows at lOh, 35m.
Lids of eyes nearly closed; pupils much dilated. Vertigo. Sits still most
of the time.

lOh. 45m. Breathing sluggish, rattling in bronchia. Noise in abdomen
every time he breathes, like wind. At lOh. 48m. spasms of epiglottis
with stiffness of jaws.

lOh. 55m. Uneasy. Pulse sluggish. Vomited about one drachm of a
greenish, slimy, watery fluid, after which became quiet and easy.

12h. 40m. P. M. Appears to be recovering. Occasionally mews. Eyes
partially closed.

12h. 43m. Administered thirty drops more of tincture. Three minutes
after attempted to vomit. Considerable vertigo. Swallowing, as if choking.
Breathing laboured. Groans slightly.

12h. 50m. Pupils dilated. Commenced running backwards. Lower jaw
drawn down almost constantly. Vertigo ; dyspnoea. Pupils dilated. Rat-
tling in lungs in breathing. Losing use of limbs. Apparently spasms of
epiglottis.

12h. 55m. Almost constant disposition to run backwards. Under jaw
drawn down towards chest, leaving the mouth open. Almost constantly
in motion. Wheezing cough. Respiration difficult. Cannot walk without
falling at almost every step., At 1 o'clock pupils very much dilated. Eye-
lids nearly closed. Breathing difficult and slow. Mouth open. Lying on
side. Tail in motion. Recognizes nothing.

Ih. 4m. Spasms of epiglottis. Paws his mouth. Under jaw drawn
down. Breathing irregular, short and difficult. Pulsations irregular and
feeble.

Ih. 15m. Aroused. Attempted to walk, but could not; lost almost en-
tirely the use of limbs.

Ih. 55m. Quite comatose. Lying on side, breathing short and heavy.
Rattling in bronchise.

2h. 20m. Occasionally an internal spasm ; occasionally a mewing noise.

1862.] Salisbury, Poisoning with the Yegetable Alkaloids.

431

2h. 40m. Partially aroused. Occasionally when he moves the tendency
is to move backwards.

2h. 44m. Severe spasms. Yomited about ^ drachm of greenish watery
fluid, after which he remained quiet and comatose till 4 o'clock.

4h. Partially aroused. Almost lost use of hind legs; drags them after
him when attempting to walk. When quiet the nose is held close to the
floor, between the paws.

4h. 5m. Administered twenty drops more of tincture. One minute after
vomited, throwing it nearly all up. Bleeds slightly from mouth. Appa-
rently in great pain. Yertigo and dimness of sight.

lOh. Quite comatose; has been so since 4h. 6m.

1h. A. M., June 13th. Quietly sleeping when I left him last evening.
Find him at 7 o'clock this morning in same position, still sleeping. Aroused
him. Appeared in considerable pain when he moved. Attempted to have
a passage from bowels. Only passed a few drops, which appeared to give
pain. Yery stupid. Yery loth to move. Appeared stiff and sore in limbs..

llh. P. M. of June 13th. Lying in same position as at ^ A. M. Been
comatose all day ; can hardly be aroused.

1h. A. M., 14th. Comatose. Lying in same position as at 11 o'clock
last evening. Breathing slow, irregular, and difficult. Mucous rattle.
Pulse slow, irregular, and feeble. Has been affected with involuntary pas-
sages from bowels for some hours.

th. 30m. Expired. A few slight spasms just before death. Body smells
as if incipfent decomposition had already commenced.

Post-mortem i\ hours after death. — Whole muscular system soft and
flaccid. No distension of venous system with blood. Length of small
intestines fifty -five inches. Length of large intestines eight inches. Outside
of stomach, lower portion of liver and mesentery covered with effused bili-
ary matter.

Stomach flaccid ; no contraction ; mucous membrane considerably con-
gested. No effusion of blood. Empty, with exception of a small quantity
of mucus adhering to walls.

Duodenum contains considerable biliary matter; slight congestion of mu-
cous membrane; otherwise healthy in appearance.

Jejunum contains fecal and slimy matter, and bile in considerable quan-
tity ; walls thin ; no contraction.

Ileum nearly empty; contains a small quantity of fecal matter and bile,
•with a little slimy mucus in the lower portion; no congestion.

Csecum, colon, and rectum contain a small quantity of fecal matter,
normal in appearance.

Kidneys somewhat congested. Portal veins full ; blood dark coloured.

•Gall-bladder quite empty.

Lower lobes of lungs in a high state of congestion ; filled with blood
and frothy mucus.

Right ventricle of heart full of blood; left ventricle empty., Yenae cavse
contain some clots ; blood, however, mostly fluid.

(Esophagus congested in spots and coated with mucus.

General fulness of vessels of brain; slight effusion in ventricles; slight
congestion of membranes.

XIII. Poisoned a Dog with three grains of Ver atria. — Dog large,
healthy, and about two years old. Length from crown of head to base
of tail twenty-eight inches. Girth back of shoulders twenty inches.

432 Salisbury, Poisoning with the Vegetable Alkaloids. [Oct.

At 12h. 10m. A. M. (a few minutes after midnight), June 17, adminis-
tered to a large male dog three grains of veratria, dissolved in about sixty
drops of alcohol.

12h. 13m. Began to shake his head and open and shut mouth, and run
around, holding mouth close to floor, as if there was severe burning in
mouth and fauces.

12h. 16m. Yomited about half drachm of white froth. Spasms of epi-
glottis. Paws mouth. Rubs mouth and side of head on floor.

12h. 22m. Spasms in throat intermitting with severe spasms of stomach
and diaphragm. Constant wagging of tail. Slight frothing at mouth.

12h. 25m. Running his head into every crack and corner. Yiolent spasms
in throat. Great dyspucea. Opens and shuts eyelids. Eyes quite natural.
Comes when called.

12h. 28m. Limbs weak; cannot walk without falling. Mouth wide open.
Intermittent spasms of epiglottis; when spasms are on, breathing ceases ;
when spasms cease breathes with difficulty and with mouth open. The
spasms and intervals last about two minutes each.

12h. 35m. When spasms are off breathes with mouth open, with the
motions and noise of lolling; with the exception that respiration, instead
of being rapid, is slow and laboured. Eyes wide open. Yertigo. Appears
to be in great pain internally ; a strong disposition to rest his abdomen on
something. Partial paralysis of nerves of motion. Sensation still perfect.

12h. 45m. Severe internal spasms ; also severe spasms of epiglottis or
muscles about the throat. Isot able to stand ; pushes his body along on
the floor by his legs. G-nashes or brings his teeth together suddenly at
every inspiration ; inspirations about twenty-five per minute. Groans ;
heart beats irregular..

12h. 50m. Recognizes when called; endeavours to approach ; looks up
wistfully, and wags his tail ; severe intermittent spasms of epiglottis and
muscles of respiration.

Ih. Breathing very slow and difficult; gasping at every inspiration;
about eight inspirations per minute.

Ih. 10m. Severe internal spasms ; severe spasms of muscles of throat ;
six inspirations per minute ; gasping and rolling over occasionally.

Ih. 20m. The same; considerable frothing.

Ih. 2Tm. Severe spasms of the muscles of the throat and of the muscular
system generally; lasted about one minute. Pulsation forty to the minute
and irregular. Brings jaws together with considerable force occasionally.
Mouth been wide open most of the time since poison was given. Opens
and shuts eyelids quite regular and natural. Pupils sensible to light; eyes
natural in appearance.

Ih- 40ra. Spasms of epiglottis very severe ; brings jaws together occa-
sionally like a rabid dog ; strikes his head on the floor with considerable
force; while in spasms rolls and tumbles about; growls; eyes still natural.

2h. 25m. The same symptoms have continued increasing gradually in
severity.

2h. 28m. Expired in a severe convulsion. Body up to fever heat.

Post-mortem 5 hovTS and 32 minutes after death. — Body warm; tem-
perature 90° Fahr. Blood unusually red and fluid ; no muscular rigidity.
Arteries and capillaries more full of blood than veins. Jugulars not full.
Mesenteric veins not full.

Bladder contained about one drachm of urine ; loose and placid.

Stomach large; no rigidity: length at upper curvature seven inches;

1862.] Salisbury, Poisoning with the "Vegetable Alkaloids. 433

length along lower curvature ten and a half inches ; cross section in widest
part four inches (walls intact and measured from middle of upper to middle
of lower curvature). Mucous membrane of a leaden colour, excepting a
small spot along the lower curvature, which was quite blue. jSTo apparent
congestion; small quantity of slimy mucus adhering to mucous membrane.

Duodenum slightly redder than usual ; walls flaccid ; mucous lining co-
vered with viscid white mucus. Length of small intestine ten and a half
feet ; length of large intestine twenty -two inches.

Jejunum and ileum contain considerable fecal matter, healthy in appear-
ance.

Cdecum, colon, and rectum healthy, and about half filled with excremen-
titious matter.

Considerable congestion of liver. Gall-bladder about one-third full of
clear bile.

Left side of heart filled with clot ; right side quite empty ; blood un-
usually red.

Lungs considerably congested, and contain a small quantity of mucus.
The arteries of lungs full of blood.

(Esophagus, pharynx, fauces, and tongue of a leaden colour.

XIY. Poisoned a Large Gat with Six Grains of Picrotoxine. — Dis-
solved six grains of picrotoxine in sixty drops of alcohol, and administered
it to a full-grown and healthy cat at 10 o'clock and 58 minutes A. M. June
21st.

lOh. 59m. One minute after swallowing the six grains, the cat went into
the most violent and rapid spasmodic motions of limbs and body. He lay
on his side ; the legs moving backward .and forward with a rapidity so
great that you could hardly distinguish them. This rapid motion of limbs
continued for about two minutes.

llh. 4m. When the motions became slower and slower, till at 11 o'clock
and 4 minutes they had almost ceased ; when frothing at the mouth com-
menced. Tongue hanging out of mouth ; pupils very much contracted ;
appear like a black line.

llh. 6m. Expired without a noise. Did not make the slightest noise
from the time the poison was given till death. The only marked symptoms
were the very peculiar rapid spasmodic motion of the limbs, the frothing at
mouth, and great contraction of pupils. Lived only eight minutes after
swallowing the six grains of picrotoxine.

llh. 7m. Whole muscular system peculiarly flaccid and lax; lower jaw
hanging loosely down ; pupils now dilated to their natural size. Picro-
toxine in this case has produced no persistent tonic muscular contraction.

Post-mortem 3 hours and 4 minutes after death. — Limbs limber and
muscles lax.

Bladder quite empty. The lower portion of it, towards the neck, was
very much contracted and rigid; the fundus thin and flaccid. Engorgement
of mesenteric veins. Length of small intestines fifty-two inches. Length
of large intestines fourteen inches ; internal diameter of large intestines one
inch ; internal diameter of small intestines one-third inch.

(Esophagus healthy. Stomach slightly contracted, corrugated, and con-
gested ; contains small quantity of food ; no efl'ased blood.

Duodenum, jejunum, and ileum healthy in appearance : slightly con-
tracted; contain fecal matter along the whole length. There is a tonic,
No. LXXXYIIL— Oct. 1862. 28

434 Salisbury, Poisoning with the Vegetable Alkaloids. [Oct.

muscular contraction of the intestines in this case, similar to that produced
by aconite, only to a much less degree.

Large intestines slightly contracted, and filled with air and fecal matter;
healthy in appearance.

Liver slightly congested around edges ; otherwise normal.

Gall-bladder quite empty; portal veins not full.

Lungs considerably congested, and filled with blood and mucus.

Heart filled with blood, partly congested. Large vessels full. Jugulars
full. Engorgement of bloodvessels of the brain and its members ; effusion
in ventricles.

XY. Poisoned a Large Female Dog with Picrotoxine. — Dog healthy
and in fine condition. Length from nose to base of tail thirty-five inches ;
girth back of shoulders twenty inches. Administered five grains of picro-
toxine, dissolved in a few drops of alcohol, at 11 o'clock and 15 minutes
A. M. June 21st. Endeavoured to get away as soon as poison was swal-
lowed.

llh. lYm. Slight twitching of muscles and winking of eyes.

llh. 19m. Opening and shutting mouth ; spasmodic twitching in mus-
cles increasing ; lolling and panting ; looks anxious.

llh. 24m. Spasms of tongue; tongue rolls up when she runs it out of
her mouth. Slight drooling,

llh. 30m. Apparently sees objects that do not exist ; staring wildly at
different parts of the room ; spasmodic twitching increases in severity.

llh. 33m. Yomited frothy matter, with a little food.

llh. 35m. Constant panting, lolling, and drooling.

llh. 3Vm. Quite a severe spasm, which threw her on her side. The legs
flew backwards and forwards rapidly for twenty seconds ; then she jumped
up as if nothing had happened.

llh. 38m. Another spasm like the first, lasting twenty seconds. Had a
passage from bowels during the spasm.

llh. 40m. Another spasm more severe; lasted something over twenty
seconds ; after an interval of ten seconds there was still another spasm,
during which there was a passage from bowels. The intervals between
spasms are only about ten seconds. Intervals shortening, and spasms in-
creasing in severity and length.

llh. 42m. Has had six severe spasms ; quiet intervals very short.

llh. 44m. Yery severe spasm; lying on side; head drawn back; legs
in constant and rapid motion backward and forward.

llh. 50m. In almost constant spasms ; passage from bowels thin and
watery ; during the short intervals lolls, pants, and looks frightened.

12h. M. Spasms have been decreasing in severity and frequency
since 11 o'clock and 50 minutes. Spasms come on now about every min-
ute, and last from five to ten seconds ; constant lolling and panting ; has
made no noise from the first, and is apparently in no pain. In the inter-
vals, recognizes when called.

12h. 14m. P. M. Administered five grains more of picrotoxin in a few
drops of alcohol.

12h. 16m. Begins to slightly affect her.

12h. 18m. Spasms increasing in severity and in the rapidity with which
they follow each other.

12h. 20m. Yery long and severe paroxysm ; limbs move with great force
and rapidity backward and forward ; snaps jaws together ; gave one bark-

1862.] Salisbury, Poisoning with the Yegetable Alkaloids.

435

ing growl ; pupils in severe spasms ; very much contracted during spasms ;
in the intervals they dilate again to natural size.

12h. 38m. Yelped three times not very loud. The paroxysm which
commenced at 12 o'clock 20 minutes is still on her.

12h. 50m. The paroxysm gradually passed off, and as it ceased she ex-
pired, which took place at 12 o'clock and 52 minutes.

Post-mortem 2 hours and 53 minutes after death. — Jugulars full. Me-
senteric veins full. Yense cavae full.

Leugth of small intestines, eleven feet and two inches ; length of large
intestines, twenty-three inches.

Diaphragm very much congested.

Bladder healthy.

Stomach about half filled with food ; mucous membrane slightly con-
gested and corrugated ; the congestion occurs in patches.

Duodenum contains a small quantity of alimentary matter ; healthy in
appearance, except a slight contraction.

Jejunum slightly contracted ; contains shreds of meat and other ali-
mentary matter.

Ileum slightly congested and contracted ; empty.

Caecum, colon, and rectum empty ; emptied by the passage from bowels
after poison was administered ; contracted and corrugated considerably.

Liver healthy. Gall-bladder about one-third full.

Lungs highly congested and filled with blood and mucus.

Auricles and ventricles of heart filled with clot and fluid blood; engorge-
ment of brain and its membranes, and effusion in ventricles.

XYI. Poisoned a full-grown Cat luith Tincture of Aconite. — Admin-
istered sixty drops of tincture of aconite (U. S. P.) to a full-grown male
cat at 6 o'clock P. M., June Itth.

6h. 5m. Commenced breathing short and laboured ; vomited ; severe
spasms ; had a passage from bowels.

6h. Tm. Breathing slow, laboured, and irregular ; severe internal spasms;
these continued at short intervals till 6 o'clock and 12 minutes.

6h. 12m. Became quiet ; very weak ; lost use of limbs ; pulsation of
heart feeble and irregular ; gasping for breath.

6h. 14m. Spasms very severe ; unable to stand; lying upon side with
limbs all extended.

6h. 16m. Expired; death sixteen minutes after administering the poison.
Yomited twice a little frothy matter.

Post-mortem 39 how^s after death. — Muscles in a state of rigid tonic
contraction. Length of small intestines, fifty-one inches ; length of large
intestines, thirteen inches.

Stomach partly filled with food ; contracted ; and mucous membrane
congested. No effusion of blood except near the cardiac orifice.

Duodenum slightly contracted ; otherwise normal.

Jejunum and ileum healthy in appearance ; contain fecal matter; slightly
contracted.

Large intestines slightly contracted and filled with fecal matter.
Liver healthy.

Bladder empty and contracted.
Extensive congestion of lungs.
Heart filled with coagulated and fluid blood.

436

Salisbury, Poisoning with the Vegetable Alkaloids.

[Oct.

Membranes of hrain congested ; congestion and effusion at base of brain ;
effusion in ventricles.

XYII. Poisoned a Large Pregnant Cat with three aiid a half grains of
Aconitia. — The aconitia was very impure ; probably not over one part in
fifty was pure aconitia. Administered two grains of aconitia to a cat,
June 18th, at 10 o'clock and 30 minutes P. M.

lOh. 32m. Commenced frothing at the mouth, and swallowing.

lOh. 33m. Yomited four drachms of food and frothy matter.

lOh. 34m. Vomited again the same; slight vertigo.

lOh. 36m. Severe internal spasms ; effort to vomit.

lOh. 38m. Severe spasms; losing use of limbs ; partial paralysis of nerves
of sensation and motion ; passed urine.

lOh. 40m. Dyspnoea; pupils dilated.

lOh. 45m. Severe internal spasms ; five inspirations per minute.
lOh. 48m. Respiration very difficult.

lOh. 49m. Severe internal spasms ; eight inspirations per minute.

lOh. 51m. Mucous rattle in bronchias; thirty short inspirations per
minute; lying on side unable to move.

lOh. 53m. Breathing very short and hurried ; mucous rattle; about sixty
inspirations per minute.

lOh. 55m. Inspirations about seventy per minute; breathing short
and hurried; mucous rattle; this state continued till 11 o'clock and 7
minutes.

llh. Ym. Severe effort to vomit; spasms severe.

llh. 15m. Respiration irregular ; pulsation rapid and irregular. Con-
tinued in this state till 11 o'clock and 55 minutes.

llh. 55m. Raised herself and walked four or five feet, severe internal
spasms.

llh. 57m. Fell upon side, breathing heavy and laboured. Mucous rattle
in bronchise; gradually improved till 12 o'clock.

June 19, 12 o'clock and 20 minutes, A. M. Gave one-half grain more of
aconitia. Lying on side quite stupid ; breathing heavy and laboured.

12h. 25m. Endeavouring to walk; staggers and falls at every step.
Limbs stiff and clumsy. Almost complete paralysis of nerves of sensation
and motion.

12h. 40m. Lying on side unable to walk ; breathing heavy and laboured.
Left the cat for the night.

1h. 13m. Cat alive; but scarcely any use of limbs. Hind legs quite
paralyzed. Pulse slow and feeble. Respiration feeble, but easy.

7h. 15m. Administered one grain more of aconitia.

th. Itm. Attempted to vomit; threw up a little frothy mucus; after
this sunk into a comatose state and remained so through the day and fol-
lowing night,

June 20th, 7h. A. M, Recovering. Hardly able to stand ; almost
complete paralysis of nerves of sensation and motion ; apparently in no
pain. Improved slowly through the day and following night.

June 21st, Yh. A. M. Able to walk with difficulty; labour pains.

June 22d, 7h. A. M. Severe labour pains.

9h. 10m. Gave birth to three kittens, two of which were dead. Kittens
about half grown. Cat finally, gradually recovered.

1862.] Salisbury, Poisoning with the Vegetable Alkaloids. 437

XYIII. Poisoned a Large Gat ivitJi Tincture of Aconite. — Adminis-
tered to large male cat sixty drops of tincture of aconite at 10 o'clock A. M.,
June 19. Cat healthy and in good condition.

lOh. 5m. Begins to froth at mouth.

lOh. 20m. Frothing at mouth and panting. No vomiting yet. Lying
on chest and abdomen. Mucous rattle in bronchise ; vertigo. Can hardly
stand ; limbs very stiff and rigid ; but little control over hind legs.

lOh. 30m. Yery severe internal spasms; vomited a small quantity of
mucus and frothy matter ; appears to be in considerable pain.

lOh. 35m. Yomited about three ounces of partly digested food.

lOh. 40m. Yery severe internal spasms, and lying upon side, unable to
walk, limbs stiff and rigid.

lOh. 45m. Severe pain, groaning and lying upon side in a deep stupor,
constant muscular twitching.

llh. 8m. Yiolent internal spasms, after which he was quiet till 11
o'clock and 30 minutes.

llh. 30m. Comatose, lying on side, breathing heavily.

llh. 33m. Yomited about one and a half drachms of bloody frothy
mucus, dyspnoea; after vomiting remained quiet till 12 o'clock and 14
minutes P. M.

12h. 14m. Yery severe spasms (internal), groaning.

12h. 38m. Quite stupid scarcely able to move.

Ih. Severe internal spasms ; groaning ; scarcely able to move a limb ;
sank into a comatose state, in v\^hich he remained till 3 o'clock and 18
minutes.

3h. 18m. Slightly improving in strength.

3h. 20m. Administered a drachm more of tincture of aconite.

3h. 45m. Gradually grew weaker till 3h. 45m., v/hen he expired. Death
took place in 5 hours and 45 minutes after administering the first dose of
aconite. After death the limbs were stiff and muscles rigid.

Post-mortem 31 hours after death. — Muscles generally rigid. Jaws
firmly set.

Urinary bladder contracted firmly on its contents ; contains about one
drachm of urine.

Stomach very much contracted, and mucous membrane corrugated and
highly congested; covered with a viscid mucus tinged with blood; no other
contents save a few small fragments the size of a pea, resembling clot ;
about half the normal size.

Duodenum very much contracted in length and diameter, and mucous
membrane highly congested and covered with mucus tinged with blood.

Jejunum and ileum contracted in length and diameter, and mucous mem-
brane congested and covered with mucus tinged with blood.

Gdecum and colon partly filled with fecal matter, thin and watery; con-
tracted in length and diameter, but less than' jejunum and ileum; mucous
membrane slightly congested in patches.

Piectum Med with fecal matter; slightly contracted; otherwise healthy
in appearance.

Gall-bladder about two-thirds filled with bile.

Liver congested around edges; portal veins full.

Lungs highly congested; especially so in the lower lobes.

Heart contains blood in both ventricles ; much more in right than in left
ventricle ; mostly fluid. Yenae cavse full of dark blood, mostly fluid. Jugu-
lars full ; mesenteric veins full.

438 Salisbury, Poisoning with the Yegetable Alkaloids. [Oct

Considerable congestion of the hrain and its membranes, and effusion in
ventricles.

Yessels of kidneys filled with blood.

XIX. Administered to a 1-iealthy Dog, weighing 35 Ihs., two drachms
of a strojig infusion of Tohacco, at 1 o'^clock and 13 minutes A. If.,
June 18. — Immediately on swallowing it commenced running around the
room, lolling and breathing rapidly.

Ih. 18m. Yomited about IJ ounces of food mixed with a little frothy
mucus of a dark -brown colour.

Ih. 21m. Yertigo. Yomited about half drachm of frothy dark mucus.
Limbs getting weak. Yertigo.

2h. Yomited several times since Ih. 27m. Still vomiting. Yery weak.
Muscles almost powerless ; cannot stand.

4h. Yomiting ceased. Strong disposition to sleep. Yery weak ; muscles
all relaxed. Eyes sunken.

5h. Recovering strength ; able to stand and walk across room.
Gradually recovered, so that at 11 o'clock A. M. of same day, nine hours
and forty-seven minutes after the infusion was administered, he appeared
quite natural. This is the dog to which I administered the tincture of aco-
nite per anum, previously mentioned; the aconite was given nine hours and
fifty-two minutes after the infusion of tobacco was administered.

XX. Administered to a Large Female Cat three drachms of Alcohol (TO
per cent.) at 11 o^ clock and 27 minutes, June 21. — 11 h. 30 m. Fell on
side intoxicated. Passed water.

llh. 40m. Same as at lOh. 30m. Mouth open. Eyes like those of a
drunken man.

llh. 50m. Lying on side. Raised head and mews when called. Muscles
all loose and flaccid.

llh. 55m. Raised up on fore feet. Has a happy look: looks around
and purs.

12, midnight. Walking about very cautiously.
12h. 20m. A. M. Quite lively; walking about room.
12h. 40m. Entirely recovered, with the exception of slight dulness. Left
her for the night.

7h. 30m. Slight indications of the first stages of delirium tremens, other-
wise quite natural, except a little prostration.

Killed the cat by fracturing skull ivith a blow from hammer, 7^ o'clock
P. M., June 17, 1853. Heart ceased to beat three minutes after. Passed
urine while dying.

Post-mortem made 10 o'' clock A. 31., June 19, 38 hours and 27 min-
utes after death. — Bladder large, loose, and flaccid; quite empty. Length
of small intestines forty-nine inches. Length of large intestines fifteen
inches. Length of stomach from cardiac to pyloric orifice five inches ;
transverse diameter three and a half inches.

Stomach nearly filled with food; no congestion or corrugation of mucous
membrane.

Duodenum healthy.

Jejunum and ileum contain fecal matter and chyle throughout their
whole length ; healthy.

Large intestines filled with fecal matter; healthy.
Lungs healthy; no congestion.

1862.] Salisbury, Poisoning with the Vegetable Alkaloids. 439

Heart contains a small quantity of clot and fluid blood. Other organs
all normal in appearance.

XXI. Administered two drachms of strong AlcoJiol to a full-grown
Male Gat, June 11. — He appeared to like it; licked his lips, and soon
exhibited signs of exhilaration. He became more active and playful. Eyes
brightened. In about fifteen minutes he began to stagger in walking, and
exhibited a disposition to hunt. Kept moving about the room. Could
perceive signs of intoxication for about an hour; after that became quiet
and natural.

XXII. Administered one drachm of Alcohol to a small Kitten, about
half grown. — In a few minutes it began to brighten up and appear more
lively. One of its mates was brought into the room. The kitten that had
taken alcohol sprang at its mate, scratched and bit it, and so frightened it
that it fell over in a fit. The stimulant effect lasted for one hour, during
which time it was very lively, and able to walk without reeling.

XXIII. Administered to a Large Gat Four Drachms of Tincture of
Aconite (U. S. P.), at 10 o'clock A. M., May 23, 1854.

lOh. 2m. Cat fell on side, swallowing, and choking and frothing at
mouth.

lOh. 3m. Severe internal spasms ; vomited about one drachm of frothy
matter; breathing short and laboured; eyes fixed and glassy; pupils di-
lated ; unable to raise on feet.

lOh. 5m. Internal spasms severe ; vomited about two drachms of frothy
matter and food; breathing becoming shorter, and more irregular and
difficult.

lOh. Tm. A severe spasm, during which vomited a small quantity of food
and passed urine. Spasm lasted about one minute.

lOh. 8m. Expired. Cat lived eight minutes after the tincture was admin-
istered. During the last five minutes he was in almost constant spasms.

Post-mortem 3 hours after death. — Muscles rigid ; jaws fixed ; urinary
bladder empty, and contracted firmly into a hard ball.

Stomach very much contracted, and mucous membrane corrugated and
highly congested in the region of cardiac orifice, where it was covered with
a frothy mucus, tinged of a pinkish colour. Stomach contained about two
and a half drachms of a darkish fluid, mixed with frothy mucus and small
fragments of food.

Duodenum very much contracted ; no congestion ; contained about one
and a half drachms of fluid matter, tinged with bile.

The jejunum and ileum were contracted, but no congestion ; contents
thin and watery. The csecum, colon, and rectum were slightly contracted,
and filled with fecal matter.

Slight congestion in lower lobes of lungs and in diaphragm.

Did not examine the brain.

Ghemical examination. — Removed the stomach and intestines, and care-
fully separated the contents, which I placed with the stomach and intes-
tines, cut fine in a large beaker glass, and subjected them to the process
hereafter described for separating aconitia. I obtained a small precipitate
in about thirty drops of slightly alkaline water, that communicated to the
tongue the characteristic and persistent numbness. This precipitate I admi-
nistered to a cat about two-thirds grown, by pouring it directly into the
throat.

440 Salisbury, Poisoning with the Vegetable Alkaloids. [Oct.

lOh. 31m. This was done at 10 o'clock and 31 minutes A. M.

lOh. 36m. Began to swallow and move about uneasily.

lOh. 40m. Frothing vslightly at mouth; eyes heavy; swallowing as if
something was in the throat.

lOh. 48m. Vomited about one drachm of frothy matter and food; slight
vertigo; breathing heavy; spasms in throat, and in region of stomach and
diaphragm.

lOh. 55m. Lying on side; breathing laboured ; internal spasms in region
of stomach, which moved the sides ; swallowing, passed urine.

lOh. 59m. Vomited about one and a half drachm of frothy mucus, with
a little food ; after which appeared easier.

llh. 15m. Lying on side, breathing easier; no frothing at mouth.

11 h. 35m. Still lying on side; breathing more natural; aroused him;
he got up and walked across the room, and lay down again.

llh. 40m. Killed the cat with a blow on the head with a hammer.

llh. 5tm. Fost-mortem. — Stomach contracted, and mucous membrane
corrugated and considerably congested ; empty, with the exception of mu-
cus adhering to the walls, and a few small particles of partially digested
meat. Mucus not tinged with blood.

Duodenum contracted and congested ; empty, except a small quantity of
mucus, mixed with bile.

Jejunum and ileum slightly contracted ; otherwise normal in appear-
ance.

Gsecum, colon, and rectum filled with fecal matter, and quite normal in
appearance. Other organs all healthy.

XXIV. Poisoned a Large Healthy Cat with Four Drachms of Tincture
of Aconite, January 14, 1862. — Symptoms before death much like those
before described. Vomited from four to five drachms of frothy mucus and
food. Passed urine. Died in thirteen minutes after the aconite was admin-
istered. About quarter of an hour after death removed stomach and intes-
tines, and subjected them to a chemical examination for aconitia, as follows :
Placed the stomach and intestines, cut fine, with their contents, in a large
beaker glass, and digested with alcohol for about one hour ; decanted and
added more alcohol, and digested again for about the same length of time;
decanted and added a third portion of alcohol, and digested and decanted.
Mixed the several portions of alcohol, and filtered through clean muslin ;
evaporated filtrate carefully at a low heat over a water-bath to the consist-
ence of a thick syrup, dissolved in two ounces of distilled water ; filtered ;
evaporated filtrate to the consistence of an extract carefully over a water-
bath, and redissolved in one and a half drachms of distilled water, acidu-
lated with SO3 filtered ; added to filtrate a strong solution of KO CO2 in
considerable excess, and set aside for precipitate to separate and subside.
At first there was no appearance of a precipitate ; after standing a short
time the liquid became slightly turbid, and at the end of twenty-four hours
quite a deposit had subsided. At the end of forty-eight hours found the
precipitate had increased. Filtered, dried filter and precipitate between
folds of Swedish filtering paper, separated as much of the precipitate from
filter as I could scrape off, and this I preserved. The precipitate gave the
characteristic taste and constricting persistent numbness of aconite on being
applied to the tongae; and produced in the throat and fauces the peculiar
secretion of viscid mucus.

1862.]

441

EEVIEWS.

Art. YII. — A Practical Guide to the Study of the Diseases of the Eye:
their Medical and Surgical Treatment. By Henry W. Williams,
M. D. Boston : Ticknor and Fields, 1862. pp. 31t.

A HANDBOOK npon diseases of tlie eye emanating from the press at the
present day, should, in onr opinion, possess two requisites. First, it
should give a clear and succinct account of the pathology and treatment
of the more common affections of the organ of vision ; and, second, it
should also sketch the results of modern investigation upon those more
abstruse topics which of late years have been so successfully studied, chiefly
by European observers. In short, it should combine such knowledge of the
past as has stood the test of experience, with at least a comprehensive
epitome of the discoveries of our own day. On these conditions alone, can
it meet the wants of the student, or claim to be au niveau with the present
state of ophthalmological science.

It is a lamentable fact that diseases of this class are, as a general rule,
but little understood by the profession. Eyes, which might readily be saved,
are lost under the care of physicia,ns who, aUhough abundantly able to cope
with the ordinary diseases met with in general practice, are "at sea in a
fog," when the delicate organ of vision is involved. It is such ignorance
that prescribes cups, blisters, low diet, mercury and tartarized antimony for
a wound of the cornea ; that poultices the eyes of an infant afflicted with
ophthahnia neonatorum until staphylomata form and burst, and the eyes
are lost ; that treats an anaemic patient suffering from granular lids and
ulcerated cornea with a darkened room, slops and various depletive mea-
sures ; that divides with the knife a vessel that reparative nature is sending
out as a healing messenger to some ulcer of the cornea ; and that profusely
salivates and starves a patient with syphilitic iritis, already exhausted by
disease and a dissolute course of life. These are a few of the many errors
which, to our knowledge, have been committed by men holding a high
position as medical practitioners ; nay, who enjoy an extended reputation
as surgeons ; errors due in a great measure to the causes stated by our
author in his preface, viz., the neglect of this branch of study at our medi-
cal schools, and the limited facilities for clinical observation of diseases of
the eye, except in our large cities. , For the sake of humanity, as well as
the credit of the profession, such ignorance should be removed ; and there
is abundant room for a convenient text -book, so cheap as to be within the
reach of all, and so free from technical terms as not to be repulsive, which
shall teach the very first principles of ophthalmology.

Something more, however, is required to complete our ideal of such a
work. The advance in our knowledge of the pathology and treatment of
diseases of the eye, and the improvement in our means of investigation,
within the last ten years, have been immense. No branch of surgery has
been more successfully cultivated. To no subject can we turn with greater
pride for evidence that the present generation has nobly fulfilled its mission
of advancing upon the knowledge of its predecessors. Witness the in-

442

Reviews.

[Oct.

ventiou of the oplithalraoscope and the many lesions that its use has revealed
to us. Observe the improvement that has been made in our treatment of
glaucoma, an affection which ten years ago almost fatally condemned its
victim to blindness, now successfully combated by a simple surgical opera-
tion. Recollect the vast labours of Bonders, opening to us a field almost
entirely new, as to the accommodation of the eye and its various lesions.
Notice the superiority of the present mode of operating in strabismus com-
pared with that formerly in vogue; the improved treatment of affections of
the lachrymal passages ; the successful application of iridectomy, not only
to glaucoma, but to increasing staphyloma, recurrent iritis, etc. ; the benefit
of iriddesis in conical cornea and certain cases of opacity ; the modern
method of extirpating the globe, etc. etc. At present a satisfactory account
of these various subjects can only be gathered from monographs or medical
periodicals in our own and foreign languages. Many of them are so novel
that they are not included in the standard works upon diseases of the eye ;
and yet they are so important that no one unfamiliar with them is fit to
practice as an oculist. It is not, indeed, to be expected that a - handbook,
intended for the student and general practitioner should contain a full and
complete account of them all ; but it should furnish an epitome sufiicient
as a basis for farther study. No work which ignores the march of science,
and which adheres to exploded theories and modes of practice, can be said
to meet the wants of the profession.

The book before us possesses the advantages of a convenient form, great
elegance of typography and ease of diction, and, when treating of some of
the more common affections of the eye, is, perhaps, as full as could reason-
ably be expected in a work designed chiefly for students ; yet we rise from
its perusal with, on the whole, a feeling of disappointment, since in both
of the respects above mentioned it fails to come up to our hopes and ex-
pectations. We propose to call attention to what we regard as some of
its merits and demerits.

The first two chapters are devoted to the methods of examining the
external and the deeper structures of the eye. In the third, we find some
excellent precepts with regard to ''remedies and their application." Our
author justly protests against acetate of lead as an ingredient of collyria.

*' Solutions of the acetate of lead, siagar of lead as it is popularly called, for-
merly had a prominent place among collyria, and are even now extensively
employed by some physicians, and especially by the common people. They
should be banished from the list of ophthalmic remedies. In cases where they
seem to be of service, the object can be better accomplished by other means
which are not dangerous to the eye, as are all preparations containing lead.
Where ulceration of the cornea exists, the solution of lead is liable to be decom-
posed and deposited in the texture of the cornea, forming an indelible opacity."

The following remarks are also excellent: —

" Vessels should not be divided with the hope of cutting off a supply from a
diseased cornea ; such an expedient could only have been devised by a superfi-
cial observer ; as in this case their development is the effect and not the cause
of the disease, and, if certain branches are obliterated after incision, others are
immediately developed in their place ; whereas they all disappear after, but not
before, the state of the cornea is improved by proper treatment.

" Local depletion, to a moderate extent, is by no means incompatible with a
general tonic treatment. Unloading the neighbouring vessels may relieve a
passive congestion, the return of which may best be prevented by giving vigour
to the general circulation.

" Poultices, whether made secundum artem, or composed of the disgusting

1862.]

Williams, Diseases of the Eye.

443

ingredients so much in favour with the vulgar, are very rarely allowable in dis-
ease of the eye itself. If applied in conjunctivitis, or disease of the cornea, they
tend to augment the discharge and to soften the corneal tissue, favouring the
formation of ulcers and perforation by the relaxation produced by the constant
application of heat and moisture.

" In traumatic injuries of the globe, we should be very sparing of our resort
to active treatment. Non-interference should be the rule, except where positive
'indications are manifest. This point cannot be too strongly insisted on."

Chapter lY., upon " affections of the conjunctiva," contains much sound
advice, which might be read with profit by the majority of practitioners of
medicine. We are surprised, however, to find upon page 80, that catarrhal
and granular affections of the lids are confounded, no distinction whatever
being admitted between the two. We regret, also, that Dr. Williams
should be so exclusive a partisan of the sulphate of copper in the treatment
of the various forms of conjunctivitis and of granular lids ; and nitrate of
silver, when properly employed, is not deserving of the entire denunciation
it here receives. A more liberal spirit would have led our author to have
endeavoured to discover the precise indications which call for the exhibition
of each of these two remedies. For ourselves, we are in the habit of treat-
ing cases of firm granulations, which prove exceedingly intractable under
the use of the sulphate, with the crayon of the nitrate lightly pencilled over
the everted lids, taking care to wash the part thoroughly with water before
it is allowed to come in contact again with the cornea. Thus applied, it
causes even less pain to the patient than a crystal of the sulphate ; and the
effect is much more satisfactory. Solutions of the nitrate of silver may
also be used with the happiest effect in many cases of muco-purulent and
purulent ophthalmia. One objection urged against them by Dr. W. is the
discoloration of the ocular conjunctiva which they sometimes produce. Now,
according to our own experience, this effect never follows, unless from the
long-continued use of a solution dropped into the eye, without any precau-
tion being taken to limit its action to the diseased surface. Hence we are
not in the habit of intrusting the employment of this remedy to patients
themselves, except in such cases as are constantly under observation, and
then only for a limited period.

When speaking of gonorrhceal ophthalmia, Dr. W. remarks : —

" Should haziness of the cornea be observed, it will be well to maintain dila-
tation of the pupil by the use of a solution of atropia or of extract of bella-
donna, that hernia of the iris may, if possible, be prevented from occurring,
should perforation take place."

This procedure, however, must be entirely ineffectual for the purpose,
since it is a notorious fact that, no matter how great the mydriasis, the
moment the aqueous humour is evacuated, the pupil contracts.

We are happy to see in the chapter upon "affections of the lachrymal
organs," that our author, in accordance with the best authorities of the
present day, condemns in toto the use of styles and tubes inserted through
an artificial opening by the side of the nose, and advocates Bowman's
method of dilatation through the natural passages, after slitting up the
canaliculus. Bowman's method, however, as here described, is so emascu-
lated, that its inventor would hesitate, we fear, to acknowledge it as his
own. For instance, Dr. W. says : —

" G-enerally, the orifice (of the canaliculus) only needs to be enlarged, and
this may best be done by inserting the point of a fine pair of scissors to the
distance of about a line, and dividing the ring surrounding the opening by a
quick stroke."

444

Reviews.

[Oct.

Mr. Bowman, on the contrary, divides the canaliculus "as far as the
caraucle," thereby g-reatly facilitating the subsequent passage of suitable
probes. Again, no inconsiderable advantage of Bo^^man's method is that
any fistulous passages which may have formed speedily heal, and the patient
is relieved in a few days from his deformity and from the flow of matter
upon the integument. Dr. W., however, prefers to perpetuate the fistula,
as we conclude from the following advice: ''When fistula lachrymalis has'
already formed, previous to our seeing the patient, it is well to take advan-
tage of the abnormal opening through the skin for the dilatation of the
duct." TVith equal propriety might a surgeon dilate a stricture of the
urethra through a perineal fistula.

In the following chapter, upon "traumatic injuries of the eye," Dr. W.
remarks: "When the entire globe is involved in the injury, and suppuration
ensues, its progress should be favoured by fomentations or poultices."
Under such circumstances, we have found excision of the globe by Bonnet's
method to be by far the preferable course, since it saves the patient several
weeks of exhausting and agonizing pain.

In describing the operation of iriddesis for the relief of conical cornea
(an operation, by the way, invented by Mr. Critchett, and not by Mr.
Bowman, as stated by our author), Dr. Williams says: "The edge of the
pupil is drawn through and allowed to form adhesions with a small punc-
ture of the cornea ;'' whereas the great merit of the 'Operation, as proposed
by its author, is that the iris is seized and withdrawn "midway between
its periphery and its pupillary margin," thereby leaving the pupillary edge
of the iris entirely free.

In the section upon staphyloma of the cornea, we find no mention of
iridectomy, as a most valuable means, in many cases, of arresting the pro-
gress of the protrusion and saving the eye.

As is well knovra to every one familiar with the current medical literature
of the last few years, Dr. Williams is a strong advocate for the treatment of
all canoes of iritis Avithont mercury — a method originating, we believe, with
himself In his earlier pubhcations upon this subject he recommended the
frequent use of instillations of a solution of atropine or belladonna, together
with quinine and iodide of potassium internally, and opiates when required
to allay pain. In his present work Dr. W. appears to have still farther
simplified his treatment, by limiting the use of remedies to mydriatics and
sedatives, the former behig considered essential, the latter merely accessory.
We are told, therefore, that in all cases of iritis the only treatment abso-
lutely necessary is to keep the pupil dilated with mydriatics; which is
equivalent to asserting that iritis, whether idiopathic, rheumatic, traumatic,
or syphilitic, is a self limited disease, which will safely run its course, pro-
vided means be taken to prevent adhesions between the pupillary margin
and the anterior capsule of the lens; and this, in fact, is the ground which
Dr. W. confessedly assumes. The beneficial effect of mercury, according
to our author, is only apparent; it happens to be given at the turning point
of the disease, and thus obtains credit which is due to the vis medicoArix
nafuree. The line of argument, however, advanced by Dr. W. to lead us
to abandon a mode of treatment sanctioned by the highest authorities is
little calculated to give us a favourable impression of the proposed innova-
tion ; since he holds up before us a bugbear in the use of mercury which
has no existence in reality, provided of course that this agent be used
according to the recognized rules of our art. Thus we read of "the inflic-
tion of the grave inconveniences and protracted convalescence often occa-

1862.]

Williams, Diseases of the Eye.

445

sionecl by the free use of mercury," and of "cases where the pupil has
become and remained obliterated by deposits, where mercury had been most
lavishly, and, as would be thought, judiciously administered." Now that
this is"^ a fair picture of the treatment of the past, we freely admit ; but
that it at all represents the practice of any surgeon educated in the modern
ophthalmic school, we emphatically deny. Xo well educated oculist of the
present day would for a moment dream of giving mercury "lavishly" in
this affection, or to the extent of depressing the vital powers. It is now
universally admitted by the best authorities that the use of this agent
should always be confined within the bounds of salivation; that the general
health should at the same time be promoted, if necessary, by tonics; and
that the pupil should be kept constantly dilated with mydriatics. How it
happens that iritis is the only symptom of secondary syphilis that cannot
be controlled by mercury; and what treatment should be adopted with a
patient suffering from iritis and other syphilitic manifestations, we must
leave Dr. Williams to settle with some writer on syphilis. But our objec-
tion to Dr. W.-s innovation does not rest on theoretical grounds alone. A
few years since, through the kindness of some of the surgeons of the X. Y.
Eye Infirmary, we had the opportunity of witnessing a faithful trial of Dr.
Williams's method of treating iritis, in which it was evident that the disease
was of much longer duration and was attended with more suffering than
where mercury was employed ; nay more, in several instances, in spite of
the faithful use of atropine, dilatation of the. pupil could not be maintained,
adhesions formed to the capsule of the lens, and vision was seriously com-
promised. We feel justified, therefore, in saying, that in his remarks upon
the supposed evils of the mercurial treatment of iritis. Dr. Y\^illiams does
injustice to his professional brethren, and that his total proscription of this
agent is dangerous and pernicious.

Let us not, however, conv-ey an impression which we do not entertain.
It is against the ultraism alone of Dr. Williams's remarks that we feel called
upon to protest. We freely admit that traumatic iritis should, as a general
rule, be treated without mercury, and this is i-n accordance with the practice
of the best ocuhsts of the present day. We believe also that many cases
of idiopathic iritis are susceptible of spontaneous recovery without injury
to the eye, provided the pupil he kept constantly dilated. Moreover, in
rheumatic iritis we often find that Rochelle salts or colchicum serve a better
purpose than the preparations of mercury. Xor would we for a moment
undervalue the use of atropine in all forms of iritis. Indeed, on this point
we are prepared to go a step farther than our author; and, instead of put-
ting a drop of the solution into the eye "once, or, in severe cases, twice in
the twenty-four hours," we are in the habit of following the German prac-
tice of repeating the instillation from three to six times a day; and we
believe that Dr. Dixon, in his excellent manual upon diseases of the eye,
is radically wrong in discountenancing the use of this agent. It is none
the less true, however, that in iritis of syphilitic origin, the judicious em-
ployment of mercury is not only safe, but, in most cases, essential to a
speedy and happy recovery; and, according to statistics collected by Graefe,
syphilis is the cause of sixty per cent, of all cases of this disease.

We had marked several passages for comment in the chapter upon cata-
ract, which our space will allow us merely to refer to. Such are the absence
of any warning against discission in old persons; the implied admission
(p. 147) that if more "convenient for the friends of the patient," a con-
genital cataract may be completely broken up at the first operation, and

446

Reviews.

[Oct.

the fragments of the lens thrust into the anterior chamber — a practice
fraught with the greatest danger, and unwarrantable under any circum-
stances unless it be the intention of the operator to prepare the eye for linear
extraction; the direction (pp. 151 and 163) "to divide the posterior as well
as the anterior capsule," a procedure which we are taught by the best
authorities most carefully to avoid; and the antiquated "rule that one eye
should not be operated on so long as the other exhibits no sign of disease."

In the chapter upon artificial pupil, an operation (irido dialysis) is de-
scribed which is now regarded as wholly inadmissible.

Dr. W.'s description of the symptoms of glaucoma is extremely imper-
fect, and he states that the object of iridectomy in this disease is "to esta-
blish a free communication between the anterior and posterior chambers;"
as though such communication did not already exist. In this chapter also
we find a doctrine perhaps the most dangerous of any taught in the book,
viz., that surgical interference is advisable in glaucoma, "unless, as we some-
times observe, the symptoms are promptly arrested by measures for the
improvement of the health of the patient." If an operation be delayed
for this experiment to be made, the golden opportunity will, in most
instances, be lost.

In no department of ophthalmology has modern research been produc-
tive of more important discoveries, or conferred a more lasting benefit on
humanity, than in the affections of the adaptive power of the eye. The
results of the unrivalled labours of Donders, first given to the world in the
Archives of Ophthalmology iov 1858, and quickly translated into every
modern language, are now recognized as affording the only satisfactory
elucidation of a subject previously slighted by many, and misunderstood by
all. It is with feelings of surprise and regret that we observe that Dr.
Williams has completely ignored the march of science in this respect, and
has recorded his adhesion to theories long since demolished.

We have but space to refer to a few of the most prominent errors. Our
author saj^s that "in ordinary eyes about sixteen inches may be regarded as
the point of most distinct vision. Any great variation from this focal dis-
tance constitutes long or short sightedness." Yet how many an individual
of middle age can read with perfect ease at sixteen inches, and is yet obliged
to use a concave glass of perhaps twenty or twenty-four inches focus for
distant objects. And how many another, of similar age, can read ordinary
type at sixteen inches, but has lost the power of making out finer without
glasses. The one is myopic, the other presbyopic, though the definition
of our author would exclude both from these categories. The mistake
consists in using the position of what is commonly called the "near point,"
or the nearest point to the eyes in which the patient sees with distinctness,
as the standard; any variation from which constitutes an anomaly of re-
fraction. It has been established that the distance of the far point is the
only safe basis of classification. And we no longer speak of myopia as
opposed to presbyopia, for, while the former (except when due to posterior
staphyloma) is an anomaly of refraction — congenital or acquired, the latter
is a sure consequence of advancing years, as much so as gray hairs, and
liable to befall all but those extremely myopic. Myopia, with the exception
just mentioned, and its opposite, hypermetropia, are anomalies of refrac-
tion; in the former the eye, when all accommodative effort is relaxed and
its far point in consequence adapted for, can receive only divergent, in the
latter only convergent rays. The one requires a concave, the other a con-
vex glass for distant objects. Presbyopia is an anomaly of accommodation,

1862.]

Williams, Diseases of the Eye.

44T

a loss of elasticity of the crystalline lens, which requires to have its refrac-
tive power increased by adding a convex glass to the eye for near objects.
It may occur as well in a moderately myopic as in a hypermetropic eye.

Our author makes no reference to the method, now in common use, for
expressing the amount of myopia, hypermetropia, or presbyopia present in
any given case ; no mention of the exceedingly simple as well as practical
plan originated by Bonders for denoting the range of the accommodation ;
no allusion to the great weight this range of accommodation in any given
case ought to exercise on the choice of glasses for that patient. One word
in this connection. "When possible," says Pr. Williams, "any one desiring
glasses should go in person to select them from the establishment of a good
optician." It seems hardly credible that a practitioner of such large expe-
rience should be willing to recommend a course that every day shows us to
be followed by such disastrous results. As well apply to an apothecary for
medical advice, or a sexton for spiritual consolation.

Dr. Williams says, referring to myopia, "Where persevering and continued
efforts are made to obviate the defect by proper training, very much may be
gained in focal distance." Modern investigation shows tliis statement to
be absolutely groundless. We admit that, as in the case of patients ope-
rated upon for cataract, practice may aid in overcoming the effect of circles
of dispersion ; that the eye may gradually get more and more used to the
imperfect images formed on its retina, and partly learn to accept an imper-
fect image for a clear one ; but this is all. The process is mental, not
optical. The image is projected on the retina, not a whit the clearer, after
ten years of unflagging training, than it was on the first day. Let Donders
speak on this point. "Diminution of myopia," says the Utrecht Professor,
after referring to his records of fifteen hundred cases, "diminution of myopia
I have never observed, either in the youth or adult, except in those rare
cases in which myopia is caused by spasm of the accommodative apparatus,
and no simple anomaly of the refraction or accommodation existed. In
old age myopia very seldom diminishes." {Archiv fur Ophthalmologie,
vol. vi. part 2, page 221.)

The chapter expressly devoted to the ophthalmoscope, and the allusions
in various parts of the work to the lesions discoverable by means of this
instrument, are so meagre and imperfect, that we fear they could hardly
have emanated from one practically acquainted with one of the most im-
-portant inventions of our day. The limits of this review will only permit
us to call attention to the important omission of any notice of sclerotico-
choroiditis posterior, resulting in posterior staphyloma, and the immediate
cause, in very many cases, of myopia. We would also remind our author,
in this connection (see p. 13), that it is not a "convex lens of two inches
radius," but one of two inches focus, that is commonly employed for
obtaining a reversed image of the fundus oculi.

It would have been a more pleasant task to have said nothing except in
praise of the present work, but we have felt obliged by the duty which
every medical reviewer owes to the profession to point out defects so glar-
ing as the above. We trust that our criticisms will be received in the kindly
spirit in which they have been intended, and that another edition of Dr.
Williams's book will leave nothing to be desir.ed to make it worthy of his
high reputation and of American ophthalmology.

In justice to the publishers, we must add that it is the most beautiful
specimen of typography that we recollect to have seen in any medical work
published in this country. A glance at the title page explains its elegance;
it comes from the "University Press at Cambridge." B.

448

PREVIEWS.

[Oct.

Art. YIII. — Health and Disease o.s ivjluencedby the Daily, Seasonal, and
other Cyclical Changes in the Human System. By Edward Smith, M.D.,
LL. B., F. R. S., Assistant Physician to the Hospital of Consumption
and Diseases of the Chest, Brompton ; Physician to the Dramatic Col-
lege ; Corresponding Member of the Academic des Sciences, Montpelier,
and of the Natural History Society of Montreal. London : Walton &
Maberly, 1861. 8vo. pp. 409.

Health: its Friends and its Foes. By R. D. Mussey, M. D., LL. D.,
late Professor of Anatomy and Surgery at Dartmouth College, N. H.,
and of Surgery in the Medical College of Ohio ; Fellow of the American
Academy of Arts and Sciences, etc. etc. Boston : Gould & Lincoln,
1862. 8vo. pp. 368.

The valuable and suggestive work of Dr. Smith particularly commends
itself to the student of biology. It has been written, as we learn from the
preface, "with a view to supply a deficiency which exists in medical litera-
ture, and to offer the results of a series of inquiries in aid of our knowledge
on the two functions of the medical practitioner — the preservation of health
and the treatment of disease." These inquiries have been made by the
author upon himself and others, both in health and disease, and have been
prosecuted almost without intermission through a period of six years.

A work in which are described the cyclical changes occurring in the
human system, and the influence exerted by season in reference to the causa-
tion and treatment of disease, cannot fail, if properly executed, to be a most
important addition to the literature, not only of physiology, but also of
practical medicine.

Yery little refl.ection is needed to show that an inquiry at once more
important and complex than this can scarcely be found in the whole range
of medical and physical science.

The complexity of such an investigation arises from several causes, and
in proportion to its complexity is the uncertainty that must, for the pre-
sent at least, attend its practical and beneficial applications. But the im-
portance of these applications is equal if not paramount to the difficulties
which beset the whole study, inasmuch as they are among the most promi-
nent of those hygienic means to which the physician philosophically resorts
in order to prevent disease rather than to attempt its cure by the employ-
ment of certain isolated and empirical formulaB.

In the great problem, to the solution of which Dr. Smith has devoted
himself with such praiseworthy zeal, several factors are given, each in a
state of activity at the same time, to determine their relation. These factors
are the healthy cyclical changes occurring in the body of man, the cause
and treatment of, and the mortality from, disease ' on the one hand, and
certain constant atmospheric changes, &c., on the other. If all or either
one of these factors were simple, the investigation would be very much
simplified, and consequently rendered far more certain in its results. But
unfortunately for the student they are compound ; each one being made up
of a number of associated elements.

Take, for example, the mortality from disease. Instead of being simple,
this is in reality a compound element. A dozen cases of a certain disease
— scarlatina for instance — may die from as many different causes. The

1862.]

Smith, Mttssey, Health.

449

specific malignancy of the malady falling upon and poisoning the nervous
centres may produce death, during the initiatory fever, either by convulsions
or coma. Or the fatal termination may be caused by a phlegmasial attack,
either of the brain, lungs, or some of the abdominal viscera. The deathward
path, for some of the patients, may lie through general debility, whether
superinduced by depressed or lessened vitality, or by some wasting, purulent
discharge. Finally, some of the cases may die from the peculiar renal
dropsy of this exantheme. Now it is within the experience of every ob-
servant physician that the climatic condition which would hasten death by
one of these modes, would retard it in another. Hence, if we content our-
selves with merely recording the mortality from scarlet fever, during a given
time, without reference to the immediate cause of death, in one column, and
opposite to it, in another column, the thermometric, barometric, hygrome-
tric, and other conditions of the atmosphere for the same time, we must
necessarily be led into error, or, at least, arrive at results so restricted and
uncertain in character, as to be of but little use. This is one source of
fallacy, which, as far as we can find, is invariably overlooked.

Again, the mortality from disease is complicated by another series of
conditions, whose positive value yet remains to be established, viz., age, sex,
height, weight, habits, modes of living, &c. This statement also applies to
the cause of disease, and to the normal or healthy course of life in man.

The climatic conditions which influence the body of man in health and
disease are numerous, and, within certain limits, constantly varying in
combination and intensity. Necessarily, therefore, their influence is a
fluctuating one. As these conditions or elements of climate — light, heat,
electricity, moisture, atmospheric pressure, &c. — are always associated, it is
very difficult to arrive at even an approximate estimate of the power of
each one, or even of the exact relation which each one bears to the other in
that series.

The science of climatology is of very recent growth. Indeed, the men
who have given to the study its scientific character belong to the present
day. Humboldt, in the admirable researches Upon the causes of the inflec-
tions of the isothermal lines, recorded in his Asie Gentrale ; Dove, by his
inquiries into the laws of the rotation of the winds ; Boussingault, in his
Economie JRurale; Ksemtz and others have all contributed largely towards
reducing to a few systematic and comprehensive generalizations the mass
of statistics which have been so rapidly accumulating during the past few
yfears. But notwithstanding the extensive and laborious observations of
many of these eminent physicists, so much that is still in doubt remains to
be generalized and reduced to simple expressions or laws, that we must
still regard as true the remark long ago made by Mason Good : "Of all
the subdivisions of general philosophy," said this writer, "there is none so
little entitled to the name of science as meteorology."

That the innumerable facts and details of disease have not yet been
reduced to their fewest and simplest expressions, none who are at all con-
versant with theoretical and practical medicine will deny. Never will there
be created a philosophy of pathology — we use this term in its most com-
prehensive sense — a philosophy in whose domains will be found the solution
of such great questions as the unity or specific diversity of disease, the rela-
tion of constitutional and local disease, &c., until the numerous and ever
varying phenomena of the healthy organism are reduced to a regular and
well defined system, in which the relation, power, influence, and cyclical
variations of each and every functional act are clearly understood.
No. LXXXYIIL— Oct. 1862. 29

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From the tenor of these remarks it . must be manifest that the satisfac-
tory study of any one of the many questions that are involved in medicine
and climatology must be very difficult, in consequence of the numerous and
variously associated elements which enter into and complicate these ques-
tions. Unable as we are to assign a true and positive value to each of
these elements individually, simply because we cannot isolate them, how
much more difficult must appear the attempt to demonstrate the relations
of the two groups — the attempt to explain a series of protean and ill-un-
derstood phenomena by another with which we are no better acquainted —
in short, to explain the complicated phenomena of normal and aberrant
vitality by the equally complicated phenomena of climate.

Calling to his aid experiment and observation. Dr. Smith, in the treatise
under notice, addresses himself to the accomplishment of this task with
marked ability.

The first chapter of his work contains an interesting account of the daily
fluctuations in the rate of the pulse and the functional activity of the lungs
and the kidneys, during the use of ordinary food and during fasting. The
method employed in the prosecution of the scientific researches here re-
corded, and the important results obtained, should be carefully studied by
the medical practitioner. After noticing briefly the well-known investiga-
tions of Kiell, Robinson, Falconer, Quetelet, Knox, Guy, and others upon
the pulse, our author says : —

"These varied and numerous inquiries have afforded much information, but
were deficient in that they did not in any case embrace the whole cycle of the
twenty-four hours, and were not made under conditions so precisely parallel that
they could be advantageously compared with each other, and hence it was desir-
able to make such a new series of observations as by their duration, the number
of persons under observation, the uniformity in the conditions of the inquiry, and
the extreme regularity in the period and mode of making the observations, should
aff'ord complete cycles and conditions which should render the results entitled
to credit. To this end two sets of inquiries were set on foot, one in reference to
health, and the other in cases of phthisis, the former embracing hourly observa-
tions on five persons, including children, and extending over three days and
nights ; and the latter on six adults of both sexes, extending over six days and
nights without intermission. The general conditions imposed were precision in
the hours of meals and of rising and retiring to rest, absolute rest during at least
five minutes before each inquiry, and rigid attention to the hour, to the order of
the cases, and to the method of counting and registering the rate of the func-
tions. The posture selected was that of lying, since that alone was possible
during sleep, and it is important to bear in mind that a considerable addition to
that rate must be made if we would ascertain the rate in the sitting and the
standing postures ; but for the purpose of showing the progressive changes
throughout the day either of the postures uniformly maintained is of nearly
equal value. The true effect of posture and its variations during the day was
determined by a third series of inquiries, in which the rate in each posture was
determined at four periods of the day in several persons in health, and at 8 A. M.
and 4 P. M. in fifteen phthisical persons during the space of a month."

Following the method of research above indicated our author has arrived
at certain conclusions which are strikingly exhibited in a series of tables and
diagrams. From these we learn that the rate of both pulsation and respira-
tion was increased during the day and decreased during the night, that these
changes did not occur abruptly, but that there was a period of increase in the
morning and of decrease in the evening ; that the amount of depression in
the rate of the pulse in relation to the greatest elevation varied in different
persons, but not in any definite relation to age, for whilst in "the elder of two

1862.]

Smith, Mussey, Health.

451

children examined the greatest rate was 2V more than the least rate, in the
younger it was ; whilst in adults it was and ^]-^ ; and in the author
himself -g]-^ ; that in reference to the rate of respiration there was a pro-
gressive decrease in this proportion as age advanced, the increase of the
maximum over the mininum being in the order of age; that the variations
in the rate of the pulse were greater during the day than in the night, in
the former three or four marked elevations alternating with an equal num-
ber of depressions; that the periods of lowest pulsation during the day were
commonly 8 A. M. and midday; and that the average increase per minute
in the rate of respiration was, after breakfast 4.4, dinner 2.1, and tea 2.1,
and of pulsation 15, 12, and 6, in the same order. Dr. Smith also found
that the increase in the rate of respiration at breakfast was sometimes more
than J, but it was less than that amount at dinner. Sometimes at both
dinner and tea no increase was observed. During the act of eating an
increase took place which disappeared in the intervals of the courses. This
temporary increase was often as high as from twelve to fifteen pulsations
per minute. The greatest increase observed in adults was twenty -three
pulsations per minute, though the effect of eating was much less pronounced
in them than in children.

The general course of the daily cycle of pulsation and respiration is thus
summed up by our author: —

"In the evening, from 7 to 9 P. M., there is an evident tendency in the rate
to decline, and with some slight variations this is continued progressively through
the following hours until from 1 to 3 A. M., when the rate is at its minimum.
During the next two hours there is a slight tendency to increase, but it is very
gradual until the usual hour of rising, when it will have attained an increase of
several pulsations per minute. Immediately after the breakfast has been taken
there is a rapid and great increase, which attains its maximum in the second
hour afterwards, after which it declines greatly in an hour, and loses from ten to
fifteen pulsations immediately before the dinner. After the dinner has been
taken there is another increase, but the rate is seldom raised so high as that
which follows the breakfast, and the highest point is attained in the second or
third hour. This again is followed by a decrease which precedes, and a subse-
quent increase which follows the tea, when a point as high as that which follows
the breakfast is usually found ; and lastly, there is the final decrease, which is
usually progressive, notwithstanding that supper may be taken at a later hour.
When dinner had been taken at a later hour than that above indicated, the rate
of the functions followed the same course as that now given, except that there
was not any important increase after mid-day until the dinner hour. The rate
remained low, but not uniform, from 12 to 1 P. M. until the dinner hour.

"The extreme difference was sometimes thirty pulsations per minute, and was
the greatest in the children,

"The ratio of the two functions varied with each hour of the day, but was
the highest during the day, and the lowest during the night.

" The ratio is dependent rather upon respiration than pulsation, so that the
high ratio of the day is due to the fact that whilst the rate of both functions is
then increased, that of respiration is increased disproportionately. The extremes
were as 1 to 2.9 and as 1 to 5.7, or the larger was double the smaller ratio; but
there was no ratio nor any progression of ratios which was absolutely uniform
on consecutive days.

"The effect of posture is very different in different persons and at various
times, both of the same and different days, so that averages give but a very
imperfect view of the result." * * * An inquiry was made upon four persons
OD three successive days in October, at 8 A, M.^ mid-day, 5 P. M., and 8 P. M.

"In both the children (examined) the effect was much greater at 8 P. M. than
at any of the other periods, and particularly the effect of the standing posture,
whilst in the adults the converse was observed. In one of the children the

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[Oct.

increase before the dinner and the supper was much greater than that before the
other meals, whilst in the elder child the effect of the standing posture was the
least before the dinner, and that of the sitting posture the least before the break-
fast. The younger of the two adults was affected by posture to a greater extent
than even the children, and at the same time the results were far more uniform
than those obtained from the latter. The progression in the decrease as the day
advanced was very striking in that case. Thus the increase in the sitting pos-
ture was 12, 9, 7.3, 3.5, and in the standing posture 27, 14.6, 12, 10 pulsations
per minute as the day advanced. The increasing effect upon the rate of respir-
ation in the children in the evening was quite as great as upon pulsation, whilst
the decreasing effect was equally well marked in the respiration of the younger
adult, in whom, indeed, the effect of posture upon the rate of that function was
then a;lmost entirely lost."

In phthisical patients Dr. Smith discovered the same progression in the
phenomena of pulsation and respiration as that recorded above for healthy
persons, but the extremes are much greater. The total rate of the functions,
he informs us, was higher, the difference between the rate in the day and
the night was much greater, and oftentimes more than forty pulsations per
minute, and consequently an increase of thirty-five to forty pulsations per
minute was commonly found after breakfast. In women the rate was ob-
served to be more uniform, and the depression of the night was greater
than in men.

"Hence, in reference to pulsation the only remarkable difference between
health and phthisis is the extreme variation in the latter of the night and the
day rate, with, as a consequence, the signal increase in the morning and the
decrease in the evening; but in reference to respiration, the singular fact was
noticed in most of the cases, that the rate increased in the night in a most evi-
dent manner, and fell in the morning on waking, so much sometimes as twelve
to fifteen respirations per minute. On the whole -average of the women, the
increase in the number of respirations was nearly seven per minute from 10 P. M.
to 11 P. M., when they fell asleep, and that there was an average, though a less
increase, until 6 or 7 A. M. The average increase in the men was 1.7 per minute
from 10 P. M. to 11 P. M., and four per minute at midnight, from which hour
the increase gradually subsided."

The next series of inquiries to which our author directs attention were
undertaken to determine the hourly variations in the amount of carbonic
acid expired and the quantity of air inspired.

Investigations of this character have been made and recorded by Coa-
thupe, Prout, Scharling, Yierordt, and others. The results arrived at by
these experimentalists are too well known to the physiological reader to
need any reference here. Coathupe and Prout sought the percentage
amount only of carbonic acid in a few cubic inches of expired air. Yierordt
noted the hour of his observations, but did not undertake to determine the
variations from hour to hour. Dr. Smith instituted an extended series of
inquiries upon four gentlemen, aged severally 26, 33, 39, and 48 years,
during the 18 hours of the working day, and upon himself in the hours
of the night. In two sets of these experiments the quantity of carbonic
acid was collected during ten minutes at the commencement of each hour,
and also of each half hour following the meals; whilst in two others, the
whole carbonic acid evolved was collected without intermission, except during
a few minutes when food was taken. In the two former, the experiments
were uniformly made in the sitting posture, but in the latter the sitting or
the standing posture was adopfed at indicated periods.

In conducting these experiments our author's method was to collect all
the carbonic acid evolved from the lungs by breathing over a solution of

1862.]

Smith, Mussey, Health.

453

caustic potass which occupied the floor of several chambers of a box of
gutta percha, and offered so extensive a surface that the whole of the car-
bonic acid was absorbed during the act of expiration. A detailed descrip-
tion of the apparatus employed would occupy too much of our space ; we
must, therefore, refer our readers for it, and the illustrative figures accom-
panying it, to the work itself.

The results obtained by Dr. Smith in this field of his inquiry are thus
recorded in his own language : —

"In experiments made to determine the amount (of carbonic acid) evolved
under the influence of not very profound sleep, it was found to be 4.88 grains
and 4.99 grains per minute, at 1 and 3 A. M. ; but we estimated the amount at
4^ grains per minute in profound sleep. Hence, commencing at from 1 to 3 A.
M., the period when the lowest amount of carbonic acid is evolved (4.88 and
4.99 grains with sleep, and 5.7 and 5.94 grains when scarcely awake), it was
found that there was an increase at about 6 A. M., when it amounted to a little
more than 6 grains per minute, and at 7 A. M., after rising, to 7 grains per min-
ute. The effect of the breakfast was to cause a total increase of 2^ to 3 grains
per minute, in from one to two hours, followed by a decrease of 1 to 1^ grains
per minute before the dinner. There was commonly an increase after dinner of
about 1 grain per minute, and usually a decrease from that period to the hour
of taking tea; but on some occasions, as on March 12, the quantity remained
high until after the tea had been taken. After tea there was again an increase
of from 1 to 1^ grains per minute, and the highest point of the day was attained.
At about 7 o'clock a fall began to occur, and the decline progressed to the
extent of 2 or 3 grains per miute at the hour of bedtime, but sometimes after
supper, the quantity remained somewhat elevated until a later hour. After
retiring to rest, at 11 o'clock, the quantity fell steadily until 1 to 3 A. M., when
the minimum was attained.

"Hence there were commonly 4 minima and 3 maxima in the daily quantities
of carbonic acid evolved, the former found immediately before each meal (except
supper) and during the night, and the latter following each meal. The largest
increase commonly followed breakfast and tea, and then the total quantities
evolved were nearly identical, whilst there was also a great similarity in the
minimum quantities recorded at the end of the intervals between the meals.
This variation was due to food, but there was a low point below which the quan-
tity did not fall. The highest amount of this variation was from one-third to
one-fourth of the whole quantity evolved. There was not any hour of the day in
which the evolution of carbonic acid was stationary, except in the hours imme-
diately preceding the breakfast."

With regard to the quantity of air inspired. Dr. Smith found that there
was a general concurrence in the progression of the quantities both of the
carbonic acid expired and the air inspired. In himself, and three other per-
sons, he discovered that the proportion of the carbonic acid to the quantity
of air inspired at rest was 1 grain to 58 cubic inches ; 54.8 cubic inches ;
58.5 cubic inches; and 54.7 cubic inches respectively.

From the foregoing statements it will be seen that, in the cycle of the
day and night, the phenomena of the pulse, respiration, inspiration of at-
mospheric air, and the evolution of carbonic acid, exhibit a remarkable
uniformity in their fluctuations, and in the manner in which they are influ-
enced by food and the digestive act. To complete the picture of this phy-
siological cycle, an inquiry into the amount of urea discharged from hour
to hour during the day is required. To this inquiry we find that our author
has also addressed himself with the effect of arriving at some novel con-
clusions.

Finding that no reliable experiments had been attempted to determine
the hourly variations in the urea and urine, he commenced a series of in-

454

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[Oct.

quiries upon himself in the beginning of 1860, and continued them on
nearly every day until March, 1861, with a view to show the variations of
urea and urine, hour by hour, under noted conditions. This resulted in the
determination of the total quantities of the twenty-four hours of the day
and night, separately, of the quantity secreted before breakfast, after the
night urine had been passed, of the quantities to twelve mid-day, and dur-
ing each two hours in the afternoon, and, lastly, of the quantity evolved at
each quarter of an hour after the breakfast and an early dinner on different
days. At the same time the fluid and solid egesta were duly determined.

After mentioning that the least quantity of urea discharged per hour was
through the night and immediately before breakfast, Dr. Smith says: —

" Immediately after breakfast, consisting of one pint of coffee, with bacon and
bread, there was a most rapid increase, so that between 9 and 12 A. M., the
quantity increased from 10 or 15 grains to 25 or 30 grains per hour, and from
12 to about 2 o'clock, the greatest amount of the day was evolved. At 4 or
6 P. M., the quantity had declined 5 to 10 grains per hour, and the decline com-
monly continued progressively until the night minimum was attained, but some-
times the quantity remained high until late in the evening. Hence the greatest
amount of urea evolved per hour is in the early part of the day, and as the day
advances the amount declines, whilst the lowest amount of the 24 hours occurs
during the night hours. The maximum period of the day is about, or soon after
mid-day, and the ascent and descent in the quantity are very rapid. A second
increase occurred at 6 to 8 P. M.

" In these experiments it is important to bear in mind that the breakfast was
a good one, and was followed by a moderate and simple dinner, without wine, at
about 2 P. M., 14 oz. of tea at 5 or 6 P. M., and 15 oz. coffee, each with bread
and butter, at 9 or 10 P. M. Hence, it was evident that the larger evolution of
urea neither corresponded with the amount of nitrogenous matter taken in the
previous meal, nor with the exertion made, but rather with the degree of activity
of the vital processes. When, however, an unusually large or unusually late
dinner was taken, with more than an ordinary quantity of wine, the proportionate
amount of night urea was considerably increased, and the increase was carried
on to the following day.

" When the food and fluid are fairly distributed over the day, as is the case
with the masses of the people in all countries, there can be no doubt that the
largest hourly excretion of urea occurs before 2 P. M., and thence forward there
is a slow but not uniform diminution to the minimum of the night. * *

" The quantity of urea evolved in each ounce of urine varies with the quantity
of water evolved, and diagram No. 6 shows that the quantity per ounce is the
inverse of the quantity per hour. Thus, in the morning hours, with sudden and
great increase of the urea per hour, there is a great decrease of that substance
per ounce, and as the day advances, the quantity per ounce increases as the
quantity per hour decreases. The opposition of the two sets of curves is most
striking, and it not uncommonly occurs that the hour of highest elimination of
urine is that of the smallest quantity of urea per ounce. ^ * * ^ * ^

The quantity of water evolved per hour is the least during the night, and
commonly there is a small increase before the breakfast in the morning. After
breakfast there is a rapid increase, so that from 1^ ounce per hour at 8|- A, M.,
there will be 4 or 6 ounces per hour at 10^ A. M., and 6 to 8 ounces per hour
at mid-day. From about this period there is a decrease, so that at 4 P. M. the
quantity is reduced to 4 ounces per hour, at 7 or 8 P. M. to 2 or 3 ounces per
hour, at 11 P. M. to less than 2 ounces, and from that point it falls to the lowest
period of the twenty-four hours. It is, however, highly probable that if only a
small quantity of fluid were taken at the usual breakfast hour, the excessive
elimination of water before mid-day would not occur, and a more uniform distri-
bution over the middle hours of the day would result. But when a large amount
of fluid is taken at night, it commonly happens that no corresponding increase
in the quantity of urine occurs on that day, but the fluid is retained, and is
emitted on the following day."

1862.]

Smith, Mussey, Health.

455

The remaining pages of the first chapter of Dr. Smith's work are devoted
to a detailed account of the results of an experimental inquiry into the
influence of fasting upon the daily progression of the pulse, respiration,
exhalation of carBonic acid and watery vapour from the lungs, and the
elimination of urea and urinary water.

In the second chapter, which is well worthy of careful study, an ad-
mirable attempt is made to utilize these results of scientific research by
pointing out their applications to practical medicine. Indeed, the work
under consideration may be regarded in its entirety as a contribution to the
science of applied physiology. In turning over its pages we feel at a loss
which to commend the more, the purely scientific investigations therein
recorded, or the manner in which the author, playing the part of the true
physician, the healer and conservator of health, indicates how the results of
these investigations may be most usefully employed as guides in the treat-
ment and prevention of disease.

The practical truths inculcated in this chapter are laid down in a series
of aphorisms, each of which is explained and commented upon at greater
or less length. These aphorisms or rules applicable to health and disease
are as follow : —

"1. In the morning hours, digestion and assimilation are performed in their
most natural, and, therefore, most healthful manner, and that period especially
demands an abundant supply of nutriment.

" 2. No one in health complains of having taken too much breakfast.

" 3. After the mid-day meal the amount of nutriment supplied should be more
limited.

" 4. With too much food supplied in the latter part of the day, there is a na-
tural desire for artificial foods, or foods of a more highly seasoned kind, and for
alcohols, and at that period such substances exert less influence upon the
organism than they would exert in the morning.

" 5. Early retiring to rest is indicated.

" 6. Food should be taken in the night only under exceptional circumstances."

Dr. Smith's experiments show that the morning is the period of greatest
vital action, and that as the day advances the food taken at the different
meals does not cause an equal increase in the rate of the functions, the
amount of urea being usually lessened hour by hour. Such facts seem to
point out the necessity for a substantial breakfast, or one in which the
amount of nutriment is of more importance than the quantity of food taken.
The drinking of large quantities of tea and coffee at breakfast would appear,
therefore, to be far less advantageous than the consumption of solid nutri-
ment. These infusions contain but little nutritious matter, and as stimu-
lators of the assimilative functions, they are less needed in the early part of
the day, when these functions are naturally active. According to our
author, milk, oatmeal and bread, and eggs, or other solid materials, should
be freely used at breakfast. As tea is opposed to nutrition, it should not
be used at this time, except when the natural powers of the system are
insufficient to produce healthy assimilation. Food should be taken in the
morning before any large amount of labour is performed, for with labour
there is increased waste, and before breakfast there is no supply. An
abundant and an early breakfast is especially essential to children, inasmuch
as the increase in the vital actions in the early morning is greater in them
than in adults. The rate of pulsation and respiration, and the evolution
of carbonic acid being the greatest in one or two hours after breakfast, and
again reduced at about four to five hours after that meal, to the lowest
point to which it falls in the working day, an early and nutritious dinner

456

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[Oct.

is required. This meal should be followed in the evening by a light supper.
At this period of the day no substantial food should be taken, except under
peculiar circumstances. For the observations of Dr. Smith show that after
the middle hours of the day, the results of the chemico-vital action within
the system are lessened, and that in the advanced evening they progres-
sively and rapidly diminish, whatever may be the amount of nutriment sup-
plied. Hence the activity of the assimilative function being lessened in the
after part of the day, there is less necessity for the transformation of food,
the introduction of which, at this time, to any extent, is more likely to be
productive of injurious, rather than of beneficial results. According to our
author, the object which should be had in view in the evening is rather the
more complete transformation ' of the food which has been already taken
than the supply of a further amount of food, and hence such respiratory
and alimentary excitants as tea and coffee are clearly called for. In cases
of great exhaustion, as in phthisis, in young infants, and in persons sub-
jected to night-watching, with or without muscular exertion, food should
be taken during the night.

The next series of aphorisms relates to variations in the quantity of
blood and the heat of the body.

" 7. The largest quantity of blood is found within two hours after each meal.

" 8. The period of the day when there is the greatest amount of blood is
usually in the afternoon, but it depends much upon the period of meals, and the
amount and kind of fluid and food taken.

" 9. The dangers resulting from excess of blood occur chiefly in the evening,
and increase after each meal.

" 10. The dangers from defect of blood occur mostly in the middle and ad-
vanced hours of the night, also in prolonged intervals iDctween meals, and after
unusual emissions of fluids.

" 11. The dangers, whether from excess or defect of blood, are materially
modified by change of posture of the body.

"12. It is believed to be well established that the normal temperature of the
body is nearly uniform, and varies but two or three degrees under whatever
normal conditions the body may be placed.

" 13. This variation results from changes in the development and distribution
of heat.

" 14. The dangers from excess of heat are the greatest at and after the middle
of the day.

" 1.5. The dangers from defect of heat occur in the night and in the early
morning.

" 16. The arrangements in reference to the clothing of the body tend to lessen
the variations of the heat of the body.

"17. Excessive clothing at night is highly injurious."

With regard to the capability for bodily and mental exertion, our author
deems himself warranted by his observations to lay down as practical guides
the following regulations : —

" 18. The period most fitted for bodily labour is from the brea-kfast until the
evening.

" 19. The night is unfitted for physical labour.

" 20. The periods most suited for mental labour are the morning and evening."

Next in order come certain generalizations relating to periods of the
attacks of disease and the administration of remedies.

" 21. In states of debility there is the greatest exhaustion in the evening and
in the early morning.

"22. In conditions of mal-assimilation of food it is important to apply all
suitable remedies during the middle periods of the day.

1862.]

Smith, Mussey, Health.

457

" 23. Fevers and similar diseases, having an increase in the evening, require
a modification of the natural arrangement.

" 24. In acute inflammation the remedies should be chiefly employed in the
middle parts of the day.

" 25. Apoplexy chiefly occurs after a meal, or in the later hours of the day.

" 26. Hemorrhage is much more liable to occur in the day than in the night.

" 27. The remedies for the states of exhaustion, as the delirium of inanition
or delirium tremens, should be applied chiefly in the evening and during the
night.

" 28. Nervous afiections are commonly the most marked in the evening and
during the night.

" 29. The period for the administration of medicines should vary with the
known mode of action of each medicine, and the hourly variations in the vital
processes of the system.

" 30. Purgatives should be always administered at night, for then there is the
greatest accumulation of blood, and of carbonaceous or other effete alvine
matter.

" 31. Diuretics should be administered with considerable frequency in the
afternoon and evening, and not in the morning.

" 32. Sudorifics are called for in the daytime, and directly after each meaf, so
long as any excess Qf food shall be found in the system. They are less indicated
in the night, and in the early morning they would be injurious.

" 33. Stimulants, when required at all, are especially needful in the early
morning and in the evening, whilst during the day they may be much less ad-
vantageous.

" 34. Sedatives, when intended to influence the whole economy, are suited to
control excess of action during the day, and may then be more freely adminis-
tered than during the natural period of decline of the vital powers in the ad-
vanced evening.

" 35. Narcotics, having a mixed action, are rather suited to the class of cases
where there is unusual depression of the vital powers, and then may be used
temporarily at any time, but for a continued action they are more suitably ad-
ministered in the late evening, since they primarily excite, and by repetition may
be restricted to that action.

" 36. Cholagogues are more called for in the afternoon and night when the
transformation of food is more urgently required."

We regret that our limits will not permit us to dwell at any length upon
the facts adduced and the reasoning adopted by our author in support of
the foregoing propositions. We recommend their perusal to our readers
with the assurance of deriving profit therefrom.

Chapter 3d treats of the weekly cycle performed by the vital operations.
■ Having established the occurrence of a daily cycle of vital changes, each
returning with regularity as the phenomena of the day appear, and each
bearing a close resemblance to those which have come before, Dr. Smith
next attempts, but with less success, we think, to demonstrate the weekly
fluctuations in the rate of pulsation and respiration, in the evolution of
carbonic acid and urea, and in the weight of the body. A weekly cycle of
vital changes is not so evident, inasmuch as the causes of recurrence are
not universal, and do not so readily attract attention. With most persons
this weekly cycle appears to be influenced; if, indeed, it is not produced, by
the institution of the Sabbath — the long-ordained day of rest to the mental
and physical organization. In the course of his inquiries at the Hospital
of Consumption, Dr. Smith found that the rate of pulsation increased
through the week and decreased on each Monday, whilst that of respiration
decreased through the week and rose on Monday. An increase in the
quantity of carbonic acid evolved was commonly observed on Monday
morning. This increase probably resulted from an unusual accumulation of

458

Reviews.

[Oct.

nutritive matter, caused by rest, and a little increase in the quantity of food
taken on Sunday. There was commonly an increased elimination of urea on
Sunday, including the day and the following night. In the whole average of
the year, to the end of February, 1861, the amount of urea evolved daily was
seventeen grains more on Sunday than on week-days, the actual quantities
being 523 grains daily on the whole average, and 540 grains daily on the
average of the Sundays. The weight of the body is highest on Sunday ;
as the week advances it is lessened, until on Saturday it reaches its lowest
point. From these statements our author infers that a periodical day of
rest is necessary to the well-being of the body if a suitable amount of exer-
tion be made daily ; and that clergymen and others whose duty calls them
to labour on Sunday should set apart another day as a day of rest.

From the early part of 1858 to the beginning of 1861 Dr. Smith was
engaged, as he informs us, in studying the influence of seasonal changes
upon the evolution of carbonic acid, the quantity of air inspired, the depth
of inspiration, the rate of pulsation and respiration, and the elimination
of ,urea, water, and other excretions. These scientific researches and the
practical applications deducible from them are embodied in chapters 4, 5,
and 6 of the work under consideration. They may be thus summed up: —

In the early part of June the amount of carbonic acid evolved began to
diminish, and continued from that to decrease progressively through June,
July, and August, until the commencement of September, when the lowest
point was attained. From this time an upward tendency was manifested,
and it continued through October, November, and December, until January,
when a point was reached from which there was little variation through
January, February, and March. In April and May the amount was yet
further increased until the starting-point was again reached. The extreme
amount of change observed was a loss of 3 grains of carbonic acid per
minute (or one-third of the maximum quantity) from the beginning of June
to that of September; a gain of 2 grains and upwards from September to
January; and a further gain of half a grain to the maximum period of the
year. The average amount of carbonic acid for the whole year, given out
at rest and before breakfast, was a little over 8 grains per minute.

"From the whole of the foregoing statement we learn that in the summer
season the amount of chemico-vital change progressively lessens, until the period
arrives when there has been the greatest accumulation of heat upon the surface
of the earth; in the autumn there is a progressive increase, by which two-thirds
is gained of that which had been lost in the summer months ; in the winter the
amount is tolerably stationary, and varies scarcely more than half a grain per
minute, whilst in the spring there is the highest amount of vital action observed
during the whole cycle of the year."

The average amount of air inspired was 425 cubic inches per minute, the
extremes being 588 cubic inches, observed on April 12th, and 363 cubic
inches on July 13th. From April to October the quantity decreased : after
October it increased. The monthly average rate of respiration was 14.3
per minute in April; from this point it declined to 10.9 per minute in Au-
gust, September, October, and November ; thenceforward the rate increased
again, but fell short of the number recorded in the previous April. The
rate of pulsation continued high during the summer months, and attained
its average maximum of 13.3 per minute in August.

The daily quantity of urea eliminated in 1860 was found by Dr. Smith
to increase steadily from March to September, except in the month of July,
when it feir somewhat. During October, November, and December, the

1862.]

Smith, Mussey, Health.

459

quantity was diminislied. In January, February, and March, 1861, it
again increased. From May to October the average daily amount dis-
charged was 510 grains; from November to April, 480 grains. It thus
appears that under ordinary conditions there is a progressive increase in
the excretion of urea as the spring advances, and throughout the summer,
until the autumnal months, when the amount corresponds very much with
that evolved during the winter. The quantity of urinary water discharged
per day during 1860, increased from March to September, when the maxi-
mum was attained, and an average increase of 13 J ounces per day was
recorded. From this time there was a progressive decrease, with a mini-
mum in the month of January, when the decrease from the maximum was
n ounces per day.

In concluding the account of this series of his researches our author
presents us with the following

^'Summary of Seasonal Infiiiences.

''Summer. — The summer season exerts the most marked power, and under its
influence the body exhibits the following minimum and maximum conditions : —

"There is the minimum of carbonic acid and vapour exhaled, of air inspired,
of the rate and force of respiration, of alimentation and assimilation, of animal
heat generated, of muscular tone and endurance of fatigue, and, in general, of
resistance to adverse influence.

"There is the maximum of the rate of pulsation, of the action of the skin,
and the elimination of vapour; of the dispersion of heat, of the supply of heat
from without, and of excess of heat; of the elimination of urea and urinary
water; of the distribution of blood to the surface, of the imbibition of fluids, of
relaxation of the tissues, and of poverty and carbonization of the Jolood.

" Winter. — In the winter season the above conditions are, for the most part,
reversed.

''Autumn. — Autumn is marked by the summer or the winter condition, as the
character of the season resembles the one or the other; but it is essentially a
period of change from the minimum towards the maximum of vital conditions.

''Spring. — In the early and middle parts of the spring season every function
of the body is in its highest degree of efficiency, but as it advances these maxi-
mum conditions merge into those of summer."

Advancing still further into the work under notice, we find that the next
eighty pages, constituting chapter 6th, are devoted to a deeply interesting
discussion as to the influence of season upon muscular power, sensibility,
viability, growth, food, disease, and medical treatment. Our author herein
displays the true Hippocratic spirit of observation. He advances, as the
matured results of his inquiries, and as he has already done in one of the
previous chapters noticed above, a series of physiological and hygienic
aphorisms, in support of the truthfulness and reliability of which he brings
forward reasons of a more or less cogent nature. Many of these apho-
risms may be accepted by the practitioner as well-established and truthful
guides. The correctness of some of them, however, we are constrained to
think is still open to discussion. Be this as it may, we deem them all of
sufficient importance to be reproduced here, especially as their recital is
necessary to complete the analysis which we desire to present to our readers.

" 1. The muscular force and power of endurance of the body varies with the
season, and the least is found at the end of summer or the beginning of autumn.

" 2. The causes of the diminution in power and endurance are four, viz. : The
rapidity of the circulation, the difficulty of maintaining a fixed temperature,
lessened chemical action, and relaxation of tissue.

" 3. Spring is the season of greatest muscular power and endurance, and then
the winter.

460

Reviews.

[Oct.

"4. The sensibility of the system to temperature and tactile impressions is
greatest in the spring and summer.

" 5. The viability of those children is the greatest who are born in the winter
and spring months, and the most suitable periods for marriage are the spring
and summer months.

6. The periods of maximum and minimum growth are spring and summer,
on the one hand, and autumn and winter on the other.

" 7. There is less variation in the amount and kind of food taken by mankind
than has been asserted.

" 8. The dangers from excess of refuse food are greater in the summer than
in the winter.

" 9. Free dejection from the bowels is more necessary in summer than in
winter.

" 10. Free emission of urea is the most necessary in spring and summer.
" 11. Spring is the season the most fraught with danger from excess of trans-
formation of food.

" 12. It is probable that nitrogenous foods are more necessary in the hot
season than we at present admit.

"13. The use of diluents is nearly equally necessary at all seasons of the
year, but for very different purposes. In winter diluents are especially needed
to enable the urea to be freely evolved. In the summer season they are chiefly
required to supply a sufficient amount of fluid for the purposes of the perspira-
tion.

" 14. The amount of blood is probably the greatest in the spring, and the
least at the end of summer.

"15. The Turkish bath may be beneficial in spring and summer, and at the
change of the seasons, but can only be useful in conditions of the system in which
there has been an undue retention of fluids, or in which the skin is deficient in
activity.

" 16. The foundation of seasonal disease is the varying degree of vital action
proceeding within the body at the different seasons of the year.

"17. There are diseases which result from an arrest or lessening of the na-
tural tendencies of the system.

" 18. The constitutional peculiarities of individuals modify the effects of season.

"19. The dangers to be apprehended in the progress of disease vary with the
season. The dangers will increase as the season progresses, and will be greatest
at the commencement of the period of change.

"20. The frequency of certain diseases has a relation to the season, and to the
nature of the disease.

" 21. Diseases of the alimentary canal have their maximum intensity and fre-
quency at the period of minimum vitality.

" 22. The greatest mortality from the plague in England occurred at the mini-
mum period of vitality.

" 23. The greatest mortality in chest diseases is found in the periods of in-
creasing and maximum vital action, and the least mortality at those of minimum
vital action.

" 24. Brain diseases prevail in the cold season.

" 25. Eruptive diseases for the most part prevail at the seasons of change.

" 26. The type of a disease has also reference to the conditions of the system
which preceded its occurrence.

"27. The rotation of the seasons is a chief element in the vis medicatrix
naturae.

" 28. The change of seasons is the safeguard of the human race.
"29. The daily habits of mankind are based upon the beneficial effects of
change of season.

" 30. The beneficial action of the rotation of the seasons is the true founda-
tion of expectant methods of medical treatment, and therefore of homoeopathy.

"31. The kind of cases which are said to be especially fitted for homoeopathy
are those' in which seasonal changes will necessarily lead to improvement of
health.

1862.]

Smith, Mussey, Health,

461

"32. The period when there is the most evident effect from the expectant
treatment is at the change of seasons.

" 33. The result of treatment in acute diseases varies with the period of the
year.

" 34. The effect of remedies varies with the different periods of the year.
" 35. The action of a remedy will appear to be very different as it acts with
or against the natural tendency of the system at the period of its administration."

Chapters T, 8, and 9 treat at considerable length of the cyclical changes
in the infantile, adult, and senile ages of man, and the practical applications
of a thorough acquaintance with these changes.

Finally, the cycle of the generations of man is ably discussed in chapters
10, 11, and 12, wherein the reader will find many interesting statements
concerning the occurrence and the causes of epidemics and the changes in
the social habits and in the type of disease in the nineteenth century.

We have thus presented our readers with a general analytical resume of
this most interesting work. At once philosophical in conception and prac-
tical in application, the physiologist and the physician will alike find in it
many valuable additions to the record of their favourite science, some of
which seem to be well established, while others, though highly plausible,
need yet a more elaborate investigation before they can be received into the
category of undoubted facts.

The work of Dr. Mussey has been undertaken and executed with a dif-
ferent object. It addresses itself to the popular rather than the scientific
reader. It has been the author's aim '*to meet the comprehension of the
general reader, and, at the same time, to present some suggestions which,
it is hoped, the young physician may find not wholly beneath his regard."

The work is divided into twenty-five chapters. The first treats of the
corset, clothing, boots and shoes, &c., and is illustrated with a series of
wood-engravings representing the various quaint styles of dress of former
epochs. The second discusses ventilation, light, sleep, exercise, and bathing.
Chapters three, four, and five are devoted to the consideration of the uses
and effects of alcohol, tobacco, tea, and coffee. Chapter six contains a
brief account of the case of the celebrated Casper Hauser. The "organic
sympathies" constitute the subject-matter of the next chapter. Throughout
the remainder of the work the author eulogizes vegetarianism, labours to
show that man is, by nature, a vegetable feeder, and points out, at some
length, the ill effects of the omnivorous practices of the human family, and
the beneficial results of a vegetable diet in the treatment of various medical
and surgical maladies. Finally, an attempt is made to show, in the last
chapter, that a purely vegetable regimen favours great length of life.

Many cases of extraordinary longevity are cited in proof of this proposi-
tion. There w^ere in the United States, in 1850, two thousand five hundred
and fifty-five persons of over one hundred years. This shows, Dr. Mussey
thinks, that about one person in nine thousand will be likely to live to
that age.

" We have not the means," he writes, " of determining to what extent human
life might be carried under the most favourable circumstances. After making
due allowance for inaccuracy of record, there is reason for believing that in
modern times some few individuals may have attained the age of nearly if not
quite two hundred years. It will be recollected that several hundred years were
occupied in abridging life — from the time of the flood to the time of Moses, who
mentions seventy years as the ordinary period; and if, during this long term,
the mischievous influences were gradually deepening their hold on Kfe, until its

462

Reviews.

[Oct.

minimum, in a particular climate and community, had been arrived at, might
not, on the other hand, most valuable results be looked for under the operation
of hygienic agencies which are within the reach of human ingenuity and effort,
protracted through a series of generations? Among these agencies, are, an
atmosphere of the highest attainable approach to purity in dwelling-houses and
public institutions; the life-quickening power of direct sunshine ; much exercise
abroad in the open air; clothing adapted to the changes of weather ; food nutri-
tious, at the same time bland and unirritating ; a drink made in Paradise, made
right at first, neither requiring nor admitting of narcotic or alcoholic admix-
tures, and a medication to extinguish disease, or abate its force, or prevent its
attack. We already possess vaccination, which can rid the world of one of the
most terrific and destructive epidemics which have invaded the human family;
we have the Peruvian bark and its extracts, which operate not only to extin-
guish marsh and lake fevers, but, when taken at suitable intervals in a malarious
atmosphere, neutralize the poison, and are a complete prophylactic or preven-
tive of an attack of the fever ; we have mercury and iodide of potassium to meet
the poison and allay the tortures of constitutional syphilis ; colchicum for the
merciless attacks of gout and rheumatism; and carbonate of iron and arsenic
and strychnia for some refractory forms of neuralgia. We have already remedies
for many parasitic animals and plants that nestle in our internal organs, or bur-
row or take root in the skin ; and as the researches of pathologists are how pushed
with enthusiasm in this department, we may anticipate for man a nearer approach
to immunity from their attacks upon comfort and life than can ever be realized
by the larger animals of the lower tribes which have no means of destroying
these invaders, while in self-made diseases, we outnumber them a hundred to one.

" The remedial means we already possess of abating the force of sweeping
diseases, or of extinguishing them altogether, reasonably inspire the hope that
choleras, yellow fever, scarlatina, typhoid and typhus, and tubercle, if not starved
out by hygienic influences, will have their remedies or antidotes, and will be met
with the same confidence as we now meet smallpox or lake fever. And if the
time shall ever come — and who does not look for a moral and physical regenera-
tion of our race, for surely one cannot come without the other — when the food
best suited to a prolonged and uniform health shall be adopted — the appetite
not left to become gluttonous like that of the beasts, but kept under the con-
scientious control of reason and science — and the only drink that of Paradise,
then there will be a progressive improvement in health, and life will be length-
ened as certainly as it has been shortened by the sottish inventions of man, the
human face no longer blotched and scarred from an empoisoned blood, but fresh
and fair, and lit up by an eye sparkling in its hundredth year. On this subject
we are not left without a cheering note from the harp of prophecy: 'There
shall be no more thence an infant of days, nor an old man that hath not filled

his days ; for the child shall die an hundred years old ; and they

shall build houses and inhabit them ; and they shall plant vineyards, and eat the
fruit of them. They shall not build, and another inhabit; they shall not plant,
and another eat ; for as the days of a tree are the days of my people, and mine
elect shall long enjoy the work of their hands.' "

Although compeUed, in view of the present teachings of physiological
science, to dissent from many of the leading views of Dr. Mussey, we do
not hesitate to refer the non-professional reader to his work as one in which
will be found an extensive and valuable fund of hygienic information.

^ J. A. M.

1862.]

463

BIBLIOGRAPHICAL NOTICES.

Art. IX. — Transactions of State Medical Societies: —

1. Transactions of the Medical Society of the State of New York, for the

year 1862. 8vo. pp. 532.

2. Communications of the Rhode Island Medical Society, for the year 1862.

8vo. pp. 195.

3. Transactions of the Medical Society of New Jersey, 1862. Ninety-Sixth

Annual Session. 8vo. pp. 116.

4. Transactions of the Medical Society of the State of Pennsylvania, at its

Thirteenth Annual Session, held in Philadelphia, June, 1862. 8vo. pp. 152.

1. The theme of the annual address before the Session of the Medical Society
of the State of New York, for the year 1862, by the President of the Society, was
"the essential dignity of the profession of medicine," and ably has it been handled
by him. No one can rise from the perusal of the address without the full convic-
tion that the calling of the physician is one which is worthy of man. To enable
him to learn how best to relieve the suffering, and to heal the sick, demands of him
his highest and most earnest efforts ; and that his mind and body be always kept
in readiness to decide upon and to act in the most critical cases, where life hangs
upon a thread. The fulfilment of all its requirements confers upon the members
of the medical profession a dignity than which none can be truer or greater.
Though upon his breast he wears no jewel conferred by any earthly power to
mark approval of his efforts in behalf of suffering humanity, the true physician
bears constantly within his heart the consciousness of approval on the part of
a power mightier than all worldly kings, and potentates and powers.

The address is followed by a very full and searching review of the medico-legal
evidence in a case of imputed murder, tried at the Oneida, N. Y., Circuit Court, in
August and September, 1861, and in which it was decided by the court and
juries before which the case was heard, that no murder had been committed,
but that the death was one of suicide. The case is one of much importance in
all its medico-legal bearings. Dr. Swinburne, of Albany, by whom the review
was drawn up and presented, has, we think, very clearly shown that the death
in this case could not possibly have been the result of a suicidal act, but was
produced by suffocation or strangulation on the part of the husband, the throat
having been cut after death, and a razor placed near the body, with the view of
leading those who first discovered it to the conclusion that a suicide had been
committed. To understand the case fully, and the true bearing of the argu-
ments of Dr. Swinburne, the review before us must be read m extenso.

The third, article comprises contributions to medico-legal science, by Dr. Chas.
H. Porter, of Albany.

The first contribution is on the Detection of Arsenic, and the second is the
history of a series of cases of Arsenical Poisoning.

Prefatory to his report of a series of cases of poisoning by arsenic. Dr. P. con-
sidered it advisable to present an account of the several methods pursued for
the detection of the poison. The writer lays no claim to originality for this
preliminary matter — it being simply a compilation from various sources. His
design is to point out a general mode of procedure in all cases of metallic poi-
soning— insuring the detection of the various toxical agents — with special refer-
ence, however, to arsenic, and again to give a systematic plan, whereby the
material can be most properly prepared for obtaining the various tests, together
with a brief description of the more characteristic chemical reagents for arsenic.

The paper is a well drawn up one. It is especially instructive in respect to

464

Bibliographical Notices.

[Oct.

the modes of procedure applicable to those cases where the particular poison is
unknown.

A careful study of the cases of arsenical poisoning, given by Dr. P., is recom-
mended to all who are so circumstanced as to render them liable to be called
upon to undertake a lego-medical investigation in cases in which a suspicion of
poisoning has been excited.

The fourth article is by Stephen Eogers, M. J)., of New York City, and is
entitled The Preventive or Prophylactic and Curative Uses of Quinine, in Mias-
matic Localities, and in Miasmatic Diseases. In whatever manner quinine,
when properly given, protects the system from the morbific influence of the air
of certain climates and localities — whether by fortifying the body in such a
manner as to prevent the action upon it of the miasmatic poison, or by so
neutralizing the specific action of such poison, as to prevent the production by
it of either of the forms of miasmatic fever — the fact of its preventive power is
now well established. By recent observations made by different individuals and
under circumstances well adapted to insure accuracy of results, the question
has been put beyond the possibility of doubt. The general deductions in respect
to this question arrived at by Dr. Eogers, are as follows : —

" First. When men are to be sent into miasmatic localities, either from ships
or from land forces, a dose of quinine., sufficiently large to produce some appre-
ciable evidence of its action, should be taken by every one before entering such
locality, and should be repeated once in twelve, and in some cases once in eight
hours during the time spent there.

" Second. Removal from a miasmatic atmosphere for any twelve hours, and
especially during a night, is quite equivalent, as a protective, to one dose of
quinine, it may be much more economical, and, when practicable, is by far the
most desirable protective measure.

" Third. In all cases where this measure can be daily practised, it will un-
questionably preserve the susceptibilities of the brain to the action of the medi-
cine, for an indefinite and probably long period, and will thus serve indirectly
as a most efficient protective.

"Fourth. Officers and chiefs in command, should by all means avail them-
selves of the advantages to be derived from such intermissions in exposure, and
thereby maintain their susceptibility to the quinine more or less unimpaired.
By so doing, the loss of their important services would be rendered much less
liable, and the consequent embarrassment to operations would almost surely be
avoided.

" Fifth. When continuous exposure is inevitable, there is no safety in attempt-
ing to protect from infection, by the use of quinine, for a longer time than two
months, and as a general rule, it is not advisable for longer than one month.

" Sixth. Ceasing its administration at this period, by the time the infection
takes place, and the premonitions appear, the susceptibilities to the medicine
will have become so restored that it will be practicable, generally, to prevent the
paroxysms for long periods of time.

"Seventh. As quinine is a stimulant, with specific action in all conditions of
depression or exhaustion from miasmatic poison and miasmatic disease, it is indi-
cated in all cases, irrespective of the state of the skin, when the unaided powers
of life are likely to be unable to restore to healthy action within the time required
to avoid a renewed attack, and also when there may be danger that the vital forces
will be overwhelmed by the poison in the onset of the disease ; and that when so
indicated, it should be promptly and efficiently employed, either by the stomach
or rectum, as the case may demand.

" Eighth. By an observance of these rules, and by avoiding the causes of
other diseases, most men, of even ordinary constitutions, can be kept in mias-
matic localities for years, in an efficient state of health."

The next article [ffth] is on Paralysis a Sequela of Diphtheria — Reflex
Paralysis, by D. D. Bissell, M. D., of Utica. Seven cases of palsy after
attacks of diphtheria were observed by Dr. B., between the 1st of July and the
middle of September, 1861. Of these, five terminated fatally, one recovered;
the remaining case still continued, though somewhat improved, after a lapse of
six months. Of the fatal cases, two, a boy and girl, about three years old, were

1862.] Transactions of State Medical Societies. 465

attacked within eighteen days after recovering from diphtheria ; two, a girl of
about three years, and a boy of ten, were attacked within twenty-five days, and
one, a boy, between six and seven years old, was attacked in thirty days.

None of these patients lived longer than fifteen days after the first symptoms
of impaired innervation became manifest, and three of them died within from
six to ten days. The one case in which recovery ensued was in a boy three and a
half years old. The attack occurred during convalescence. In this case nearly all
the motor muscles, including those of speech and deglutition, were paralyzed.
This state of things continued about thirty days, when the patient began to
articulate, and the muscles of the neck and trunk to regain their power, and soon
after those of the limbs also. During this time, a period of nearly six weeks,
the patient slept well, had a good appetite, a clean tongue, regular bowels, and
a normal condition of all the secretions and excretions. The pulse was always
small, soft, and very rapid, and the surface cooler and paler than natural. The
recovery in this case was rapid and complete ; and, at the end of six months
and more the patient was in good health, with the free use of all his muscles.

The boy, in whom there was, after six months, persistent paralysis, was about
four years old, healthy and strong for his age, when he was attacked with diph-
theria— which was mild and of short duration; his recovery seemed perfect.
Symptoms of paralysis set in at the end of three or four weeks ; and in a week
subsequently he had lost all power of locomotion, and in a great degree the use
of his hands and arms. There was no difficulty of deglutition, and the voice
and tongue were not afffected.

All these patients, with a single exception, had nearly or quite recovered their
usual health, when attacked with paralysis. The earliest symptoms were an un-
steadiness or staggering and dragging of the limbs when attempting to walk,
with formication and tenderness in the muscles of the thigh, leg, etc. There
was a greater loss of power and co-ordination than of sensibility in the parts
affected. Usually, the muscles of the neck, arms, and hands become enfeebled,
and soon after, in some cases, those of the pharynx and tongue become more or
less involved in the disease. In two instances portions of fluids which were
attempted to be taken, were returned through the nose, while solid substances
were more readily swallowed. Vomiting, towards the close of the disease,
occurred in a few cases. The pulse was in all cases soft, feeble, and easily
counted, in most it was infrequent — sometimes not more than thirty beats in a
minute. In two or three instances it was very quick and feeble, scarcely to be
counted. The surface of the body was paler and cooler than natural, the mus-
cles everywhere having a doughy, inelastic feel, but without any considerable
atrophy. The appetite remains good, digestion is perfect, the bowels regular,
the alvine discharges normal, and the urine natural in quantity and healthy in
appearance.

There were no indications of ursemic poisoning. There was no pain of the
head or tenderness of spine ; no apparent lesion of the cerebro-spinal organs.
No coma. The mind was always clear and usually cheerful ; the sleep quiet and
natural. The respiration corresponded with the pulse, being slow when this
was slow, rapid when it was rapid. The lungs and heart presented no indica-
tion of organic lesion.

Death usually occurred suddenly ; when the patient was sitting up talking with
those around him, or amusing himself with his toys, life would become in an in-
stant extinct, without a groan or the distortion of a muscle — probably in conse-
quence of paralysis of the heart.

Our knowledge of the pathology of the paralysis which succeeds to an attack
of diphtheria is very limited. Dr. Bissell conceives it more than probable
that impaired nutrition in the periphery of the sentient nerves, either from im-
pure blood or a diminished supply of arterial blood, is the exciting cause — the
outward excitation of Brown-Sequard. The morbid impression cast upon the.
cerebro-spinal axis, though a reflex action, manifests itself in a partial or gene-
ral paralysis according to the locality from which such reflex action proceeds.
The higher the point of reflexion, the more general the consequent paralysis.

The following are the conclusions of Dr. Bissell, in respect to the proper
No. LXXXYIIL— Oct. 1862. 30

466 Bibliographical J^otices. [Oct.

treatment of the paralysis under consideration, drawn from tlie cases wliich have
fallen under his notice : —

"1st. Rest, as perfect as is practicable, on the back, with the head, arms, and
legs well elevated, to favour the descent or ' gravitation of blood to the spinal
cord;' friction to the spine and limbs, when it can be applied without causing
exhaustion or fatigue ; the external application of a warm solution of sulphuret
of potash to the surface, to increase the action of the dermoid tissues and capil-
lary vessels, and wrapping the body in warm flannels, not only become valuable
auxiliaries to, but constitute an important part of our plan of cure.

" 2d. Strychnine given repeatedly, in small doses, so as to avoid constitutional
effects — the 40th or 30th of a grain, five or six times a day — is the remedy most
entitled to confidence.

3d. The pyrophosphate of iron ranks next to strychnine in our available means
of cure. It may be given either in solution, or in a pill, in doses of from three
to five grains, three or four times a day.

" It is of the highest importance in the cases of reflex paralysis, such as de-
scribed, that the treatment should be commenced during the first stage of the
disease, and as soon as the loss of power in any of the muscles begins to mani-
fest itself."

Next follows a case of Healed Ulcer of the Stomach, discovered after death,
from ulceration of the duodenum, by J. Knebland, M. D., of Onondaga Co.,
N. Y. The most important feature in this case is the fact established by it,
that organic disease of the stomach of frightful extent and productive of great
suffering and disturbance of function for months and even years, is capable of
being relieved or even cured.

J. R. BouLWARE, M.D., of Albany, relates a case of Wounded Trachea —
with obstinate vomiting, congested lungs, suffocation. The subject of it was
an apparently healthy female, 23 years of age, who attempted suicide by cut-
ting her throat with a razor. The crico-thyroidean membrane was wounded,
and the cricoid cartilage and upper ring of the trachea, together with several
small bloodvessels, were divided. The edges of the wound were drawn to-
gether and retained by adhesive plaster. At the end of three weeks, with the
exception of a small opening in the trachea just below the cricoid cartilage,
the wound had healed. The edges of the opening were touched with caustic
and drawn together by adhesive strips. A collection of mucus took place in
such quantity as to threaten suffocation. To get rid of this the wound was
reopened and a tube inserted. After a few days the tube was withdrawn and
the opening dressed with adhesive plaster. It soon began to contract and
respiration to be slightly impeded. The contraction of the wound went on
diminishing the calibre of the trachea, and causing such urgent dyspnoea as
to require the opening to be enlarged and a tube inserted. After several
weeks the tube was withdrawn and the wound again dressed with adhesive plas-
ter. At the end of eleven weeks from the time it was inflicted the wound was
entirely healed, and remained' closed for five days, when the dyspnoea became
again so intense that it was necessary to reopen the trachea ; instant relief was
the consequence. The opening was just below the cricoid cartilage ; a large
tube was worn in it constantly. The patient now began to lose her voice ; in a
few weeks it entirely disappeared.

When the opening in the trachea was closed by the finger suffocation would
immediately ensue. The patient, nevertheless, could speak in an audible whis-
per. Her articulation constantly improved up to the period of her death. By
placing the ear close to her mouth she was able to convey readily her ideas in
an audible whisper. To within a few days of her death she enjoyed excellent
health. Considerable difficulty being experienced in expectorating mucus
through the tube, this was withdrawn, and with the forceps several portions of
tough mucus were removed from the trachea, affording instant relief. Similar
attacks followed, each becoming more intense. They were preceded and accom-
panied by violent and distressing vomitings.

All th.e symptoms increased constantly in urgency, the dyspnoea became more
intense, the countenance livid and anxious. She finally died with all the symp-
toms of suffocation, nineteen months after the receipt of the wound.

1862.]

Transactions of State Medical Societies.

46t

On examination after death, both lungs were found congested; their tissue
was healthy, with the exception of a small portion near the apex of the left
lung-, which was of a reddish-brown colour and softened, readily sinking in water,
presenting the appearance of pneumonia in the second stage: the bronchi and
lower portion of the trachea were almost completely obstructed by masses of
viscid mucus, with which blood was so intimately incorporated as to give to it
a pale dingy red colour throughout. Many of the smaller bronchial tubes were
also completely obstructed by the same kind of mucus. The canal of the larynx
was found to be completely obstructed at the upper portion of the cricoid car-
tilage by a dense white fibrous tissue : on examination the latter was found to
be perfectly organized and firmly attached to the inner surface of the cartilage,
extending to its lower border and filling up that portion of the larynx included
within the lower third of the cricoid cartilage, entirely impeding the passage of
the air. The portion of the trachea immediately below the larynx was con-
tracted to one-third of its normal size. The remaining organs of the body pre-
sented no lesions of any account.

The next article [eighth) is entitled Medical Provision for Railroads as a
humanitarian measure, as well as a source of economy to the Companies.
Dr. E. Arnold, of Yonkers, Westchester Co., N. Y., has treated the subject
set forth in the title of his communication with great ability. Facts which
indicate the probable risk of accident involving more or less serious injury to
the passengers and employees, on a railroad, and the necessity, in the majority
of these cases, of prompt surgical assistance for the relief of suffering and the
preservation in many instances of limb or even of life, show the propriety of
medical provision for railroads as a mere question of humanity. This position
is strongly enforced by Dr. Arnold. While he has shown also, with equal clear-
ness, that as a simple matter of economy, railroads are bound to make such
provision in justice to the stockholders, whose funds are almost annually
depleted by heavy damages recovered as a compensation for injuries sustained
by passengers — .which injuries, and the amount of pecuniary compensation in
consequence awarded, would very often be materially lessened were surgical
assistance always provided at the moment when it is most demanded, and
when it would also be most efficient.

Dr. H. S. Downs, of New York city, relates a Case of Peritonitis occurring
in a female child ten years old, in which enormous doses of opium were admin-
istered. The cure was effected at the end of about thirty days.

According to the statement of Dr. D. the patient took during eleven days of
the period of greatest suffering, 148 grs. of morphia, one bottle of McMunn's
elixir of opium, and half an ounce of Magendie's solution of morphia, besides
having 20 grs. of morphia sprinkled upon the blistered surface of the abdomen,
and a quantity of laudanum and opium given in the form of enemas and suppo-
sitories. She also inhaled a considerable amount of chloroform. The largest
quantity of morphia taken on any given day, was. twenty-eight grains. On ano-
ther day she took a bottle of McMunn's elixir of opium and twenty-four grs. of
morphia. During her sickness her mind was upon the whole clear and rational;
nevertheless, since her recovery she does not appear to remember anything which
occurred previously to the 23d day of her sickness, not even a large blister over
her abdomen, which remained perfectly raw for more than a week.

A case of Cirrhosis of the Liver, Enlarged Spleen, and Abnormal Distribu-
tion of the Vessels between it and the Stomach, by Dr. M. M. Marsh, of
Onondaga County, N. Y., constitutes the tenth article. The most interesting
abnormal appearances detected after death in this case were those of the liver
and spleen. The liver was bilobed and completely cirrhosed throughout, with
almost entire arrest of circulation through it. The gall-bladder, nevertheless,
was filled with apparently healthy bile. The liver was of less than the normal
size ; it weighed three pounds seven ounces. The splenic artery was so dilated
as to easily admit the thumb one-fourth the length from its distribution ; a
branch passes from it to an exactly duplicate spleen, about the size of the
healthy organ, and suspended from the upper large spleen by a membrane as
the liver is from the diaphragm. The weight of the superior spleen was fifty-
eight ounces, healthy in appearance, and, in place of the usual distribution.

468

Bibliographical Notices.

[Oct.

sending two parallel vessels to the stomacli, each equal in diameter with the
enlarged splenic artery, and apparently penetrating the coats of the stomach.
The vessels were so much softened as to prevent their dissection. The sto-
mach, otherwise apparently healthy, opposite the place of connection of these
vessels had its mucous coat and a portion of its muscular ruptured. On being
washed, torn muscular fibres were detected for more than one inch in extent
around this part. The peritoneal coat was entire.

The points of interest in this case, according to Dr. Marsh, are, that there
was, during the life of the patient, no evidence of diseased structure or function
of the liver ; the existence of a softening of the aorta without observable fatty
degeneration ; the unique occurrence of an absolutely duplicate spleen attached
by membrane to the parent body; and, the extremely rare circumstance of two
immense vessels supplying the place of the vasa brevia.

The eleventh article is A Protracted Case of Lameness, by Dr. Hiram
Corliss, of Washington County, N. Y. The subject of this case strained his
ankle when eighteen years of age. After a few weeks he recovered, and re-
mained well until he was twenty-one years old, when he again strained his ankle.
This was in the summer of 1851, the patient being then a student in an eastern
college. The sprain continued to be troublesome until the spring of 1852. In
the May of the latter year the patient whilst walking experienced a slight pain
beneath the left patella. The next morning the knee was much swollen above
and below the joint, and inflamed. The lameness continued about the same in
extent for more than a year.

The treatment consisted chiefly in the application of iodine, blisters, bandages,
and the affusion of cold water. During the spring and summer of 1853 he was free
from disease. In the fall the patient had a severe attack of typhoid fever. On
-recovering, he commenced the life of a student in New York, and was compelled
to climb daily several flights of stairs. At the end of about two months, the
disease of the left knee returned, attended with a dull heavy pain at the lower
part of the spine. Kelinquished his studies and tried a variety of remedies.
Took a sea-fishing trip for a month. Pain ceased in the back ; lameness not
materially improved. Commenced teaching in the fall of 1854. Lameness con-
tinued until the summer of 1855, when it again ceased, and the knee gradually
recovered its strength. In the winter of 1856, the patient teaching in a large
boarding school, pain and swelling of the right knee took place. It recovered
its healthy condition in the ensuing summer. There was no renewal of the
attack during the next two years, though the patient was engaged in teaching a
day school. In the spring of 1859, six weeks after the patient had again com-
menced teaching in a large boarding school, the swelling and lameness of the
left knee reappeared, and two weeks subsequently of the right knee also. The
pain in the lower part of back returned likewise. In the spring of 1860, the
right knee became well, and in the summer the left knee began to improve and
continued to improve up to February, 1862. In the fall of 1860 the right knee
was again attacked, and continued affected up to the early part of the present
year, occasionally improving and relapsing. Both knees are somewhat altered
in form by deposition around the joints. There is not, nor has there been any
pain excepting when the affected limbs are used.

Temperament of patient, nervo-sanguine. Habits, strictly temperate ; in-
dulges in no debilitating vice. General health always good. Sleeps well ; has
a good digestion ; never has the blues.

Blistering and rest have generally appeared to act favourably in respect to
the left knee, but unfavourably as regards the right one. Application of muri-
ate of ammonia reduces for a time the swelling, but exerts no permanent effect.
No benefit, but, occasionally, injury was experienced from the use of iodine,
cups, leeches, poultices, liniments, setons, etc.

Art. 12. This is the history, by Dr. T. C. Ftnnell, of New York city, of the
case of a female child, nine years old, in which an attack of dysentery ivas fol-
lowed hy acute 'peritonitis, when a spontaneous opening at the umbilicus oc-
curred, through which a large quantity of pus was discharged, when entire reco-
very ensued.

The attack of dysentery had lasted four days previously to the child being

1862.]

Transactions of State Medical Societies.

469

seen by Dr. F. Small doses of morphine every two hours were directed. At
the end of ten days the symptoms of dysentery had entirely disappeared. There
was a desire for food, and the child sat up in bed, and was rapidly recovering.

Five days subsequently, symptoms of acute peritonitis set in, with tenderness
over the abdomen, tympanitis, high fever, intense thirst, etc. At the end of
four days, the presence of a fluid within the peritoneal sac was evident. Five
days later, the fluid had increased in quantity ; tongue clean ; pulse 100 ; bowels
regular; some difficulty in breathing from distension of abdomen. This condi-
tion of things continued with little change for upwards of three weeks, when the
umbilicus, which had gradually become red and tumid, gave way, and four
pounds of pus, yellow in colour, of the consistence of cream, aud free from
odour, were discharged. No collapse or other unpleasant symptom followed.
The child experienced great relief after the opening occurred. The discharge
diminished day by day. At the end of two months the opening at the umbilicus
was closed, and in a few weeks later the health of the child was completely
restored.

Art. 13. Malignant Pustule in the United States. By Dr. A. N. Bell, of
Brooklyn. — In presenting a sketch of the several occurrences on record of the
disease in this country, Dr. Bell gives a very faithful description of it, together
with a brief notice of the leading facts illustrative of its etiology.

According to Bourgeois, the latest authority (Paris, 1861), in the human
subject malignant pustule occurs most commonly on the face, and next on the
hands, neck, and arms — very rarely on the trunk. There first occurs a painful
swelling, upon the central portion of which, within most generally three days,
a small reddish or purple spot appears, attended with itching. In the course of
twelve or fifteen hours at this spot a vesicle is formed, usually about the size of
a pin's head, and filled with a reddish-brown or yellowish fluid. The vesicle is in
general quickly ruptured by scratching, or it dries up within thirty-six hours,
leaving the denuded skin dry, and mostly of a livid colour. Itching now ceases.
Within twenty-four hours the centre of this discoloured part grows hard, and
becomes surrounded with a number of small vesicles like the first. Within the
areola the part is hard, depressed, and of a colour varying from yellow to black.
There is now more pain than at any other stage. The disease is, however, in
general unattended with severe pain. Within the next twenty-four or forty-eight
hours the disease penetrates to the subcutaneous cellular tissue, and extends
in circumference ; in consequence of the induration of the affected parts, their
limits can be determined without difficulty. The central brown or livid part
soon becomes gangrenous, and if it cease to progress, the dead portion is sur-
rounded by a circle of vivid redness, a sense of agreeable warmth is experienced,
with a pulsatory motion at the seat of the disease. The pulse increases in
strength, and to the fever and nausea there succeeds a gentle perspiration and
quiet stomach. Suppuration now occurs around the dead portion of the pustule,
these become detached, and a suppurating surface, varying in extent in diff'erent
cases, remains. In unfavourable cases suppuration does not ensue ; the gan-
grene extends from the centre to the circumference of the tumour ; the pulse
becomes smaller aid more contracted ; there is extreme lassitude, wakefulness,
fainting fits, and complete indiS"erence as to the result ; disinclination for food
or medicine; total loss of appetite. The tongue is dry and brown ; the features
are shrunk ; the skin is parched; the eyes are glassy. Cardialgia and low deli-
rium precede the fatal event : which takes place ordinarily in from five to eight
days. In very malignant cases death takes place very promptly, with the mani-
festation of but few symptoms.

The disease varies somewhat in different cases. In some it assumes the form
and runs the course of phlegmonous erysipelas.

It is laid down by those who have had the best opportunities for investigating
the disease, that malignant pustule in the human subject is caused by an animal
poison derived from diseased animals or their remains. Herbivorous animals
affected with malignant carbuncle ; cows affected with trembles ; the flesh and
blood of overdriven animals, or of those who have died of gangrene of the lungs.
It is by contact with the bodies or blood of such diseased animals that usually
man contracts the disease, though it is said that partaking of the milk, flesh, or

Bibliographical ^Iotices.

[Oct.

butter from sucli animals will likewise communicate malignant pustule. Although
it is, perhaps, not true that the flesh, etc., of diseased cattle will give rise to that
disease by introducing a specific poison into the system of those who partake
of them as food, yet there are numerous facts on record which would seem to
show very clearly that in persons nourished for any length of time upon the
flesh of diseased animals, malignant pustule is especially liable to make its ap-
pearance.

Art. 14. Strictures of the Urethra, and Means for their Treatment. By Dr.
Jas. M. Minor, of Kings County, N. Y. — The main object of this paper is to
recommend a form of metallic sound by which to facilitate the passage of small
filiform elastic bougies. For a description and drawing of the instrument, with
directions for its employment, we must refer to the paper itself.

Art. 15. Strictures of the Urethra. By Dr. J. H. Hobart Burge, of Brooklyn,
N. Y. — This paper is devoted to an account of certain improvements which the
writer has made in an instrument for dilating strictures of the male urethra,
which was described by him in the published Transactions of the society for 1861.

Art. 16. A New Instrument, proposed by Dr. J. H. Hobart Burge, /or the
removal of foreign bodies from the oesophagus, and the other passages or deep
cavities ; for dilating the cervix uteri in cases of dysmenorrhoea; as a speculum
for the ear and nose; as a probang, by inserting a piece of sponge between the
blades ; to convey a tape through the nostril, for the purpose of plugging the
posterior nares; for the removal of nasal polypi; for the removal of the seques-
trum in cases of necrosis; and. as a useful surgical forceps generally.

The instrument is in the form of a pair of forceps, twelve inches long, with
parallel blades, hinged together by a pivot, running the whole length of their
straight portion about seven inches. The extremity of each blade is curved for
a distance of five inches ; the blades are perfectly smooth externally, but rough-
ened on their inner surfaces, where they come in contact. The handles are at a
right angle with the shaft. In the handle is a screw, by which the blades can
be slowly and forcibly separated, and thus fixed.

Art. 17. The Points of Election, and the Kind of Operation for Amputation
of the Lower Extremities, with reference to the use of artificial limbs. By Dr.
Douglass Bly, of Rochester, N. Y. — As far as this paper goes, the suggestions
embraced in it are particularly sound. It is, however, not sufficiently elaborate
to enable the surgeon to select the place and manner of amputating, so as best
to adapt the stump for the application of a useful artificial limb. The saving
as far as possible of the integrity of the movable articulations, and of the
insertion of the muscles for the motion of the joint, is one grand desideratum.
When joints cannot be saved, the amputation must then be performed, when
practicable, so as to give ample room for the arrangement and motions of a firm
practicable joint in the artificial limb supplied. The decision can only be made
after a careful study of the form, mechanism, and mode of application of the
latter, with reference to the nature and extent of the injury by which amputation
was necessitated.

We believe with Dr. Bly that the antero-posterior double flap operation is
the proper one to be performed whenever the surgeon htis the privilege of
choosing.

Art. 18. Case of Suffocation, with Pathological Specimen. By J. R. Boul-
WARE, M. D., of Albany, N. Y. — This is a very curious case. The patient, a
boy, eight years old, subject during infancy to spasmodic croup, some time pre-
vious to his death had had an attack of pulmonary inflammation. Had for about
two weeks complained of momentary attacks of pain about the centre of the
sternum. Was seized in the evening with a severe attack of this pain, accom-
panied by an eff'ort to vomit, with symptoms of choking. During the following
night and next morning experienced several similar attacks. He went to play
in the street. About an hour before noon he complained of feeling bad ; he lay
down upon a bed, seemingly occupied in studying his next day's lesson. Soon
after he rose from bed and rushed wildly into the next room, violently agitated
and struggling as though in a state of strangulation, with protruding eyes and
livid face. He continued thus for a very short time, his struggles becoming
more and more feeble until death ensued.

1862.]

Transactions of State Medical Societies.

On dissection the only important lesions were those detected in the lungs and
trachea. The healthy portions of the lungs were distended with air to their
utmost capacity — when the thorax was opened they did not collapse, but bulged
out of the pleural cavity. The upper third of the superior lobe of the right
lung was hepatized ; on the anterior surface of this indurated portion near the
apex, was a cicatrix of a dense fibrous structure, an inch and a half long and
a quarter of an inch broad near the middle, tapering to a point at each end.
The surrounding pleural surface was considerably puckered. The lower lobes
of the lung were healthy. The left lung, the tissue of which was healthy, was
firmly adherent to the costal pleura. The indurated portion of the lung, when
divided, was found to contain several encysted tubercles ; some of the size of a
small walnut and softened. The bronchial glands were enlarged. One as large
as a hen's egg was situated just above the right bronchus between the trachea
and vena cava ; it was firmly attached to the bronchus and right side of the
trachea. When divided it was found to contain a light grayish substance of a
cheesy consistence. This and the deposit in the lungs presented under the
microscope the usual characters of tubercle.

On carefully opening the trachea along its posterior wall, at its upper part
was found a grayish body of a tough cheesy consistence, three quarters of an
inch long, and having a circumference sufficient completely to plug up the cavity
of the trachea. It pressed firmly against the rima glottidis and completely pre-
vented the egress of air from the lungs — thus accounting satisfactorily for the
distended condition of the air cells of the lungs, the symptoms of strangulation
and the sudden death of the patient. On laying open the trachea as low down
as the enlarged and adherent iDronchial gland, an opening was discovered through
the walls of the bronchus, communicating with the interior of the tuberculous
gland. By this opening it is evident that the matter of the plug at the upper
end of the trachea had been admitted into the cavity of the latter.

Art. 19. Remarks on the Treatment of Hemorrhage on the Battle-field, ivith
notice of a newly-invented Tourniquet for Military and Civil Service. By Dr.
Charles A. Lee. — Though there is nothing especially novel in the remarks of
Dr. Lee, they are all particularly sound and practical, and may be consulted with
profit by the large corps of military surgeons which the necessities of the civil
war in which our country is now engaged have recently called into existence.

So great is the loss of life among troops engaged in battle from hemorrhage
either immediately, or indirectly from the shock and exhaustion caused by it — •
and the almost impossibility of professional aid being aff'orded with sufficient
promptness, to every one whose wounds have given rise to dangerous hemor-
rhage, that every officer and soldier of an army should be instructed as to the
best and simplest means of arresting the flow of blood from a wounded artery ;
whilst it is made their duty, as far as circumstances will render it practicable,
to apply these means sufficiently early to save life. Even though the means
are in the majority of cases only temporary, death may be prevented in the
greater number of instances, while the services of a large number of the
wounded would be saved who would otherwise necessarily perish or after linger-
ing for a long time in hospital be finally invalided.

The tourniquet recommended by Dr. Lee is the elastic tourniquet of Lambert,
which has been introduced by authority into the American army, as a field
tourniquet.

Art, 20. Caries of Elboiu-joint, Operation of Excision, with recovery of a
useful Arm. — The history of this case by Dr. Husted, of New York city, is a
particularly instructive one. The patient's life was in all probability saved by
the operation of excision ; and what is better, she has been restored to health
with increased strength, an elbow-joint with no particular deformity — having
perfect flexion and extension and nearly perfect pronation and supination. The
limb is shortened about two inches.

Appended to the paper is a history of the operation of excision of the
elbow-joint drawn chiefly from the monograph of Dr. Hodges, of Boston, on
excision of joints. According to the latter, excision in traumatic cases is a
safer operation than amputation, whilst by it usually a limb of considerable
usefulness may be preserved. Excision for anchylosis is only adapted to cases

472

Bibliographical Notices.

[Oct.

where the arm is in a straight position or in one of extreme flexion. In exci-
sion performed in cases of diseased joint, death occurs once in nearly eight
cases ; and in its failure to remove the disease and preserve a useful arm, exci-
cision fails once in three and a half cases. Partial excision, either for traumatic
or organic lesions is a frequent cause of unfavorable results.

Art. 21. Dislocation of the Femur into the Ischiatic Notch — Reduction hy
Manipulation — Death from Rupture of the Bladder. By Dr. J. C. Hutchi-
son, of Brooklyn, N.Y. — The patient, a labourer, 40 years old, was struck over
the lower portion of the back by the bucket of an elevator which fell from a
considerable height. The result was dislocation of the head of the right femur
into the ischiatic notch, a fracture of the pelvis through the right acetabulum,
and perhaps rupture of the urinary bladder. Death on the fourth day after the
accident.

The chief interest of this case arises from the opportunity afforded by it for
a dissection of the dislocated joint, after the head of the bone had been restored
to its socket by manipulation.

On raising the gluteus maximus, a considerable quantity of extravasated
blood was found beneath it ; the portion of the muscle situated over the tuber
ischii was ruptured, so as to make a depression large enough to imbed the
tuberosity. Gluteus medius and minimus uninjured ; lower edge of the pyri-
formis, gemelli, and the upper portion of the obturator externus lacerated ; the
capsular ligament lacerated posteriorly through one-half its extent; round
ligament torn from the depression in the head of femur. The latter in its
normal position in the acetabulum. On flexing the leg, which required consi-
derable force owing to its rigidity, a fracture was revealed, by a loud crack ; it
was found to extend from the upper portion of the ischiatic notch through the
acetabulum. There was no displacement, the fracture, probably at first incom-
plete, was made complete by the force used in bending the thigh. The bladder
was ruptured at the fundus ; no urine detected in peritoneal cavity ; death caused
by peritonitis.

Art. 22. A curious case is related by Dr. C. Burrows, of Clinton, N. Y., in
which an oblique fracture of the femur, just below the trochanter major, was
caused in a lad by a violent attack of spasms of the limb.

Art. 23. Polypus Uteri and its Treatment. By Wm. Gilfillan, M. D., of
Brooklyn, N. Y. — A case of uterine polypus which is related by Dr. G. leads him
to examine generally the subject of polypous growths within the womb — their
diagnosis, and means of removal, with especial reference to the ease with which
they may be detached by torsion. Dr. G. urges the early removal of these growths
in all cases when not contraindicated by coexisting pregnancy. When intra-
uterine with undilated os, he recommends dilatation by sponge tents or other
means, to prevent the loss of the patient from the repeated hemorrhages that
would be liable to occur if the removal were delayed. Even when frequent
uterine hemorrhage occurs, the cause of which is not apparent, he recommends
artificial dilatation of the os and cervix uteri, so as to permit an exploration of
the uterine cavity. He further believes that long and repeated hemorrhages
and the so called menorrhagia may be caused by the presence of a small polypus
in the uterus.

Art. 24. Laceration of the Perineum, with destruction of the recto-vaginal
septum; operation; Result, a strong perineum of normal breadth and thickness.
Case related by Dr. Chas. C. F. Gay, of Bufialo, N. Y. — The operation per-
formed in this case was that recommended by Dr. Marion Sims, with the addition
of dividing the sphincter ani, and the postponement of the use of the rectal tube
until the seventh day after the operation. Dr. Gay believes that the success of
this case was mainly attributable to the employment of two sutures to hold
together the bowel portion of the laceration.

Art. 25. Case of Triplets. Reported by G. Furman, M. D., of New York
city. — There is nothing very novel or especially instructive in this case.

Art. 26. Summary of Meteorological Observations made in the City of New
York. By Dr. J. P. Loines. — -This paper does not admit of any useful analysis.
The same may be said in reference to the next paper.

Art. 27. Abstract of Hecdth Officer's Report, City of Brooklyn. Communi-
cated by Dr. Mason.

1862.]

Transactions of State Medical Societies.

Art. 28. A case of Enlargement of Spleen and Liver. By L. Briggs, of Au-
burn. Communicated by Dr. Alden March. — Excepting in the obscurity which
appears to have marlced the etiology of this case, it does not appear to have
differed in its leading features from the cases of extreme enlargement of the
spleen and liver usually met with.

Art. 29. Conservative Surgery : with a list of the Medical and Surgical Force
of New York in the War of Rebellion of 1861-'62. Alphabetically arranged.
By S. D. WiLLARD, M. D., of Albany. As an historical record this paper will be
found hereafter deeply interesting, and not without a certain amount of value.

Art. 30. Report of the Specicd Committee upon the United States Drug Law.
— The very able committee from which this report emanates — composed of dele-
gates from several of the medical societies of New York, and from the New
York College of Pharmacy — was appointed with the view of taking some de-
cided action to secure, if possible, the proper execution by the federal adminis-
tration, of the law " to prevent the importation of adulterated and spurious drugs
and medicines."

The suggestions contained in the memorial presented by the committee to the
Secretary of the Treasury are judicious, and if carried out would no doubt have
more effectually secured the systematic and faithful execution of the law in
respect to the inspection of imported drugs. The work undertaken by the com-
mittee remains, however, so far, unfinished, though we have, perhaps, some faint
hopes of better success in the future.

Of the ensuing three papers we need only present the respective titles.

Art. 31. Report upon the United States Pharmacopoeia, February, 1862.

Art. 32, Report of a Special Committee upon Communications remonstrating
against Homoeopathy. From the Oneida County Medical Society and the New
York Academy of Medicine.

Art. 33. Report of the Committee on Medical and Surgical Statistics.

The volume closes with Biographiccd Notices of deceased members of the
Society, and an abstract of the proceedings of the session of 1862.

2. The first of the communications of the Rhode Island Medical Society for
1862 is an address by Dr. B. Lincoln Ray, on the hereditary transmission of
disease. The subject is handled by Dr. R. with great ability. From the facts
and principles presented by him he deduces the following general conclusions,
namely : —

"First. From healthy and unconsanguineous ancestors j)roceeds a posterity
of which a very large proportion are born perfect, sound, and with tendencies
towards healthy development and healthy procreation. Second. From unhealthy
or consanguineous ancestors proceeds a posterity of which a very much less
proportion are born perfect, sound, and with tendencies towards healthy devel-
opment and healthy procreation. Or, to make the correlative statement : Healthy
and unrelated ancestors produce a posterity of which but a very small propor-
tion are imperfect or unsound ; while unhealthy or related ancestors produce a
posterity of which a very much larger proportion are imperfect or unsound."

The second communication is the history of a case of rupture of the heart.
By Dr. Augustine A. Mann. — The patient, a farmer seventy-two years old, short
of stature, and weighing 215 pounds, had for a period of four years suffered from
rheumatic pains, especially during the winter. He was also troubled with short-
ness of breath on any slight exertion. During two years had gained much in
flesh. February 19, 1861, he was suddenly seized with dyspnoea, a sense of
constriction at the upper part of the chest, and a severe pain at the prsecordia
and in the left side extending to the arm. It was especially severe over the
region of the heart. Pulsations of the latter 120 per minute, full, strong, and
occasionally bounding. The cardiac sounds well defined and distinct, but feeble
when compared with the impulse of the organ and the pulse at the wrist. For
a few days there had been a slight cough, but no chill, fever, or pain in the
shoulder. Sleep rather restless. By the next day the pain had extended to
back and lower limbs. The difficulty of breathing not increased by the recum-
bent position. Stricture of chest gone. During the night there was a short
hacking cough, with mucous expectoration streaked with blood. No bellows

Bibliographical Notices.

[Oct.

sound of heart. Posterior lobes of lungs gave, upon auscultation, a distinct,
coarse, mucous rale. There was no dulness upon percussion. Centre of tongue
covered with a dark moist fur. The patient gradually improved up to the 23d,
when he considered himself nearly well. Two days later, in the evening, he was
supposed to be dying. He was pale and haggard, and suffered from extreme
dyspnoea ; his forehead was bathed in sweat. He complained of severe pain at
the apex of the heart. His breathing was irregular ; he felt a sensation of stric-
ture at the upper anterior part of the chest. Pulse 60, feeble, small, and irre-
gular. Sounds of heart feeble and indistinct, with a faint, continuous, ringing
tone. Slight mucous rale heard in the lungs. It was very distinct, however,
next day, at the upper anterior portion and the lower posterior portion of the
chest. Expectoration as before, and abundant ; dyspnoea less, but breathing
still short and rapid. Some nausea. Tongue has a thick, dark, dry coating ;
urine scanty and high coloured. The patient gradually improved up to March
1st, when Dr. Clapp saw him. He agreed with Dr. Mann, that the case was
one of cardiac disease, probably fatty degeneration. No effusion was detected
in either of the cavities. Pulse 88, small, feeble, irregular ; tongue dry and
furred ; urine scanty. Twelve days later, oedema of the lower extremities ; at
the end of three days, there was probably an effusion into all the large cavities.
Cough and expectoration slight ; pulse 90, improved in character ; tongue
moist, with dark fur along its centre; urine scanty, high coloured. The patient
became soon weak and unable to sit up ; had pains in the cardiac region, with
stiffness and soreness of limbs. Dyspnoea intense upon the slightest exertion ;
countenance expressive of pain and anxiety ; delirium at night. On evening of
March 18th, all the symptoms more urgent. Severe pain of heart, left side, and
arm ; intense dyspnoea ; extreme paleness ; dilated pupils ; free perspiration.
Pulse at wrist could not be felt ; heart beat feebly, about 60 strokes a minute.
Next morning the symptoms were less urgent. Legs much swollen ; increased
effusion in chest ; expectoration much tinged with blood ; more distinct rales ;
great dulness of chest on percussion ; pulse irregular, scarcely to be counted.
But slight change occurred until April 1st, when the weakness and dyspnoea were
extreme ; the delirium greatly increased ; pulse more feeble and irregular. The
patient now sank rapidly, and died on the evening of April 5th.

The following are the lesions discovered after death in the chest, and the only
ones of importance : In the pleural cavities about two quarts of serum ; some
adhesions of the left lung to the costal pleura. The entire pericardium firmly
and closely adherent to the surface of the heart. Heart large, surrounded with
much fat ; its muscular tissue soft and easily torn. The aorta, for three inches,
dilated to nearly twice its usual size; no sign of obstruction in any of its
branches. Walls of right ventricle very thin and soft ; its cavity large. Left
ventricle partly filled by a large fibrinous clot, weighing nearly three ounces.
In the upper and anterior part of the wall of this ventricle a cavity was found
containing about two ounces of dark offensive pus ; between the cavity and
ventricle the fibrinous clot formed a septum. The walls of the ventricle were
very thin, particularly near the apex, as was also the intra-ventricular septum.
The muscular tissue covering the cavity containing pus was extremely thin.

Cholera Infantum. By Dr. W. Owen Brown, of Providence. — This is a very
good exposition of the treatment of the disease. It presents nothing, however,
especially new. In the chronic form where the leading symptom is diarrhoea,
the stools being watery and of varying consistency and colour, with extreme
marasmus, there can be no doubt that quinia and iron are among our most
valuable remedies. Spirits of turpentine in such cases, when judiciously ad-
ministered, will often be productive, promptly, of the best effects.

Supplementary Mammce. — A case of this rare anomaly is related by Dr. H. E.
Turner, of Newport. Coincident with the secretion of milk in the mammae, in
a female recently delivered of her first child, a gland in each axilla became
enlarged, and secreted milk in such quantity that a decided stream could be
impelled to a considerable distance. There was neither nipple nor areola. The
largest c-f these glands was of the size of a large shellbark ; the other was rather
less. They had all the appearance of distinct supplementary mammae.

1862.]

Transactions of State Medical Societies.

4Y5

Paralysis following Diphtlieria. By Dr. G. L. Collins, of Providence. —
The patient was a boy two years and a half old. Three weeks after he had been
discharged well of diphtheria, he was attacked with cough, hoarseness of voice,
and a failure of muscular power. A week later the symptoms were as follows :
Cough, with frequent paroxysms of severe dyspnoea; voice almost extinct ; when
erect, the head fell from side to side ; the chin usually rested upon the sternum,
until the centre of gravity was changed ; upper eyelids drooped over the eyes,
and could not be raised by an effort of the will ; pupils largely dilated ; sight
and hearing undisturbed ; countenance devoid of expression ; power of muscles
of upper extremities unaffected; muscles of legs totally paralyzed ; rectal sphinc-
ter not materially paralyzed, that of the bladder wholly so ; the urine not albu-
minous, but loaded with earthy phosphates ; difficulty of swallowing fluids, a
portion of them often regurgitated through the nostrils ; power of memory ap-
parently lost. The patient was put upon the use of citrate of iron, was bathed
daily in sea-water, was allowed to partake freely of nourishing food, though for
a time only a small quantity could be taken because of the difficulty of swallow-
ing. After the symptoms had continued for some days to increase in extent, they
remained for a short time stationary, and as gradually improved. The paralysis
had nearly disappeared at the end of eight weeks from the period of its com-
mencement. The patient was still, however, somewhat feeble and anagmic.
After a short residence in the country, he was completely restored to health.

Notices of Dysentery in the year 1861, compiled by Dr. C. W. Parsoxs. —
During the summer and autumn of 1861, the dysentery appears to have pre-
vailed pretty extensively in nearly all of the villages of Ehode Island, situated
along the Pawtuxet River and its branches. The symptoms and course of the
disease presented nothing very peculiar. It was not attended by any severe
mortality. In respect to treatment. Dr. Parsons remarks, " that the cases of
dysentery which prevailed at the period and places indicated, were marked by
great collapse of the surface, clammy perspiration, and general prostration,
rendering it almost always necessary to combine with the remedies more especi-
ally appropriate to the disease a stimulating tonic." Dr. P employed the syrup
of rhatany and whiskey ; and, he informs us, with the best results. For the
collapse and debility of the general system he used tannin combined with opium
and ipecacuanha, with an alkaline mustard wash. He reprobates the too free
and indiscriminate use of opium. He considered it a most important remedy
but would have its employment watched and guarded with the utmost vigilance.
In some instances the dysenteric symptoms yield very suddenly under the use of
opium. In these a continuance of the remedy beyond the necessary point is
liable to be attended with serious consequences.

Report on Surgery. By Dr. H. E. Turnee, of Newport. — The report em-
braces three cases. The first case is one of comminuted fracture with depres-
sion of the skull. Dura mater uninjured. No reaction occurred. Death took
place, without return of consciousness, at the end of thirty-two hours. Dr.
T., queries whether those cases of injury of the head in which the dura mater
is not torn, are not more liable to terminate unfavourably, than even apparently
more extensive injuries, where the dura mater is divided, hernia cerebri being
produced, or even a portion of the cerebral substance destroyed. The second
case is one of tumour on the side of the pelvis, occurring after an injury in an
adult male. Sloughing having taken place at two different points in the tumour,
it was extracted by the knife. It was of a firm, cartilaginous structure, and
weighed about a pound. The patient had a favourable recovery.

The third case is one of dry gangrene of the right foot, in a man forty-eight
years of age, from extensive ossification of the arteries of the right lower limb.
Amputation was performed at the earnest solicitation of the patient, below the
knee. On the sixth day after the operation, tetanus set in, and the patient died
on the succeeding day.

Examination of Recruits, with Medical and Surgical Cases. By Dr. J.
Gardner, of Providence. — The most interesting portion of this report is that
in reference to typhoid pneumonia, which, at one time, it was feared would be
quite prevalent among the soldiers. Nine cases of the disease occurred nearly
simultaneously. Seven were in the hospital, and two in the city, all being mem-

4t6

Bibliographical Notices.

[Oct.

bers of one command quartered in tlie arsenal. All had at first catarrhal and
gastric symptoms ; these were followed })j stupor, more or less delirium, pain,
d3'spnoea and cough. The pain was sometimes acute, at others more or less
obtuse. It sometimes extended to both sides of the chest and to other parts
of the body. The expectoration was invariably more or less mixed with blood
giving it a brick-coloured appearance. Pulse at commencement of attack gene-
rally full, but weak and compressible ; after the sixth or seventh day it became
more frequent, from one hundred to one hundred and twenty, small and very
feeble ; skin hot and dry ; tongue coated with brownish fur, very dry in the ad-
vanced stages ; teeth and gums more or less encrusted with dark sordes. While
the morbid phenomena varied somewhat in different cases, the same leading cha-
racteristics were present in all.

In respect to treatment. When the arterial excitement was considerable, and
the inflammatory symptoms were intense, a careful and persistent use of the
veratrum viride was found to be a useful and potent remedy. In one case, the
pain was so intense and continuous, that venesection was resorted to with the
most beneficial results. With these remedies were given, every four hours, a
combination of one grain each of ipecac and opium, and from one to two of
calomel, alternated with expectorating and demulcent beverages. By the fifth
or sixth day of the disease the calomel, opium and ipecac, were suspended. If
there still remained pain and dyspnoea, sinapisms and epispastics were indicated
followed at bedtime by ten grains of Dover's powder or a sufficient dose of ano-
dyne balsam (?) to procure sleep. Subsequently the acetate of ammonia was
given every three or four hours, alternated with one to two grain doses of quinine,
with b&ef tea, wine whey, etc.

All but one of the cases recovered. The fatal one assumed a chronic cha-
racter, and the patient was transferred to his native city, Boston, where he
subsequently died.

3, The printed Transactions of the Medical Society/ of New Jersey, for 1862,
open with the address of the President, Dr. J. Blaxe. His theme is "The
Medical Society of New Jersey, and the objects and duties of the physicians
and surgeons its members." It is very well handled. The address is replete
with interesting historical reminiscences, and with suggestions which, if carried
out by those to whom they were addressed, cannot fail to eventuate in the per-
manent good and honour of the profession of which they are members.

In the report of the standing committee we are presented with a brief sum-
mary of the reports received from the several district societies. From these
several reports we learn that scarlatina prevailed to some extent over a large
portion of the State of New Jersey. The disease varied in its severity and
fatality in different localities. No new facts in reference to the disease are given
calculated to throw additional light upon its pathology or treatment.

Diphtheria, also, has been very prevalent in many parts of the State, exhibit-
ing the same variety in respect to its severity and fatality. Generally speaking,
it has been less malignant than during the two preceding years. In one district
the deaths were mostly from prostration of the vital powers. In another from
obstruction of the trachea. In one place in many of the cases, whether fatal or
otherwise, sore spots occurred on the fingers and toes, with exudation, extremely
obstinate under treatment. The sequelae of the disease, as far as noticed, were
great nervous prostration, loss of voice, paralysis of muscles of throat, causing
difficulty in swallowing fluids, these being often ejected through the nose. In
one case there was occasional total blindness, which lasted for six weeks.

In respect to the treatment of diphtheria there is a very general agreement as
to the propriety of supporting and antiseptic measures ; but a difference of opinion
exists as to local treatment. Severe local applications to the throat are con-
demned by many. The deposit being the local manifestation of a constitutional
disease, and death resulting, excepting in croupal cases, from the toxaemic effects
of a poison, no good can result, but, on the contrary, much injury, from attempt-
ing its artificial removal, A saturated solution of tannin, applied with a camel's-
hair pencil, or the frequent application by the same means of a chlorine mixture,
will be found more generally beneficial than more severe remedies. A powder

1862.] Transactions of State Medical Societies. 411

composed of equal parts of chlor. potass, and rock candy rubbed together and
put upon the tongue every half hour is an excellent application, especially in
cases of children.

Rubeola has been less than usually prevalent, but with no distinguishing fea-
tures requiring notice.

Variola has prevailed to a very great degree in some portions of the State.
Generally speaking the amount of mortality produced by it has not been very
great. The epidemic has revealed the fact that there is a very large proportion
of the population of New Jersey that has not been vaccinated.

An affection variously styled Malignant Pustule, Malignant or Carhuncular
Erysipelas, is noticed as having occurred in Hunterdon and Essex Counties.
Some eight cases are reported, of which tiuo occurred in May and June, 1851 ;
five in July, 1861, and one in August. In all cases the disease occurred upon
the upper lip, and sometimes upon the nose also, causing enormous swelling of
these parts and of the face and neck, in some instances very painful, in others
almost painless. The disease was of a highly malignant character, and generally
fatal in its termination. The disease appears in the form of a pimple of the size
of a pea, of a livid colour and hard to the touch. General system in some cases
but little affected. Dyspeptic symptoms and fetor of breath commonly present.
Some few cases were attended with restlessness, great distress, irritative fever,
headache, etc. Death in some cases was preceded by coma. We gain little that
is reliable in respect to the treatment of this affection, nor in regard to its true
character and etiology.

From a careful review of the facts set forth in the reports from district Soci-
eties bearing upon the history of malaria in New Jersey, the following general
conclusions would appear to be fully sustained : —

1st. That there is a general subsidence of malarial diseases throughout the
State, and in almost all the counties from which reports have been received,
intermittent fever may be said to have ceased to appear.

2d. That swamps, ponds of water, and streams liable to overflow their banks
are universally regarded as the prolific causes of miasm, while the drainage of
the country, etc., and the cultivation of the reclaimed soil are as universally
regarded as the certain means of its extinguishment.

3d. It is nevertheless manifest that these local causes are not at all times
equally potent in the production of malaria, but that other and more hidden
influences are to be looked to as equally efiicient in its development. Some law
of periodicity would seem to govern the rise, progress, and subsidence of epi-
demics, the cycles of which are governed by causes which are yet to be discovered.

4th. It is a common observation that when intermittent fever ceases to pre-
vail, remittent and continued fevers take its place. This has been observed in
the alluvial districts of New Jersey, and in the more recently settled portions
of New York and Pennsylvania.

. Independent of the history of the prevalent epidemics of the year 1861, the
reports from the district Societies contain the history of a number of interesting
cases, both medical and surgical, and many observations in reference to the
endemic and sporadic diseases which fell under the notice of those who contri-
buted to their preparation.

Dr. PiEESON, of Essex, details a case of Pyaemia. It occurred in a male, 20
years of age, from, it is supposed, suppressed gonorrhoea. When seen by Dr.
P. he was suffering from irregular chills and fever. He was about, but very
weak and staggering in his gait; experienced almost constantly a dull aching
pain in the iliac region and in the right shoulder; the rigors increased constantly
in severity, with fever and profuse perspiration; the pain extended to the region
of the liver; the debility continued. In twenty-eight days after Dr. P. sawhim
he died with all the symptoms of typhoid fever.

Dr. J. S. Martin, of Middlesex, reports a case of Strangulated Hernia in a
female 61 years of age, which produced sloughing of the abdominal walls, which
finally healed with a restoration of the natural outlet. Since her recovery four
years have elapsed, during which period she has enjoyed entire health, and though
living an active life, has not experienced any inconvenience in the part where
sloughing occurred.

Bibliographical Notices.

[Oct.

Dr. GooDENOUGH, of Monmouth, notices a case of Anasaira whicli occurred
at the seventh month of a first pregnancy. The most distressing feature of this
case was the enormous infiltration of the labise externse, which, with the dis-
tressing pruritus and smarting, forced the patient to lie upon her face to obtain
any rest. The only remedy from which relief was obtained was the subnitrate
of bismuth, dusted upon the parts after they had been washed with tepid milk.

Dr. A. B. Dayton, of Monmouth, describes the case of a woman, 80 years of
age, in whom the distension of the bladder from retained urine caused a com-
plete mechanical obstruction to the passage of the feces, giving rise to enormous
intumescence of the abdomen and great distress. No passage from the bowels
could be obtained until the bladder was emptied by means of the catheter, when
a free stool immediately ensued.

Besides the reports from the District Societies we have one from the Scientific
Committee on the question, " Can nervous diseases be considered less mechanical
or chemical than other organic complaints ?" The committee are of opinion
that a large majority of nervous diseases are not, strictly speaking, organic, but
functional, sympathetic, symptomatic.

" Because," they remark, " we do not fully understand certain nerve phenomena
there is no occasion to presume that they are the results of mechanical or che-
mical change. It is better always in the theories of medical science to await
the accumulation of facts and the proofs of practical experience rather than
classify too hastily. It is better that medical facts should stand on the cold
border-land, unclassified, than be forced into rank and file before their proper
place is clearly ascertained."

The report closes with an extract from a letter written by 0. Handfield Jones
to a member of the committee, which contains some excellent remarks on the
question under discussion. The extract is as follows : —

"As to whether the nerve cells and fibres are not morbidly changed in their
molecular composition in nervous diseases, I can only say that the case seems
to me not proven. Function and structure do not appear to be ver^ closely
linked together. In the neurolytic form of paralysis all the phenomena are those
of debility, plain and unmistakable ; the treatment that benefits is tonic and
stimulating, such as seems to act by arousing and increasing the natural vital
endowment, not by removing some impediment to its exercise. When we admi-
nister hydr. bichloride in chronic cerebral affections, or pot. iod. in rheumatic
cerebral disorder, it is very probable that we do act on the aflPected tissue in a
way of changing its composition. But when we still delirium with opium, or
prevent fatigue with the same narcotic, or remove a palsy by strychnine or gal-
vanism, the action appears to me to be more purely dynamic. The same, I think,
must be true of malarious disease. Quinine is no antidote for malaria ; a man
may be saturated with the drug and the poison remain in full force. Quinine
seems only to do in ague what it does in various other instances, namely, impart
a tone and force to the nervous system, enabling it to withstand the morbid
agency. In the same way it acts as a protective, and this action, which is very
significant, is paralleled by that of mental stimulus. Excitement and animation
will preserve men from succumbing to malarious disease as surely as depression
will promote its injurious effects. All this, to my mind, is much more like dyna-
mic than organic alteration. I know of two instances where persons resided a
long time in aguish districts, numbers being affected around them, yet they had
no symptoms of disease until they left the locality, and then they both had it.
In these instances it is certain that either the nervous structure was altered
during the residence, or that it was not. If it was, then we have change of
structure without symptoms ; if it was not, then the symptoms, on removing,
must have been owing to some dynamic change. The production of convulsions
by ligature of the arteries, of paraplegia by peripheral irritation, ceasing on the
removal of the latter, looks to me much more like disorder from dynamic than
from organic alteration. One can hardly suppose that the gray cerebral matter
is instantaneously modified in its composition by the interruption of the circu-
latory current, although it must feel the loss of the blood pressure. So, if a
paraplegia is rapidly improved by the removal of a distant irritation, it seems
reasonable to suppose that the nervous centre was only embarrassed in its act-

1862 ]

Transactions of State Medical Societies.

419

ing, not cTianged in its structure. A more perfect knowledge of the action of
remedies, which seems to me the great desideratum of the day, will aid us much
in deciding the question."

The present volume of Transactions closes with a brief biographical notice
of Frederick S. Weller, M. D., of Patterson, N. J., by Dr. A. W. Eogers.

4. The annual address delivered before the Pennsylvania State Medical So-
ciety, at the opening of its session of 1862, by the President,- Edward Wallace,
M. D., of Berks, is a very neat production, and in its sentiments well timed ;
whether viewed in reference to the imperfect representation, at the sessions of
the State Society, of the medical profession in Pennsylvania, or to the existing
condition of the latter, and the duties which are incumbent upon its respective
members to raise its efficiency and character, and secure its true interests.

The address is followed by a well written and well conceived circular, addressed
to the physicians throughout the State, urging upon them to perfect the organi-
zation of the profession everywhere into county societies.

Reports were received from only eight counties. From those we learn, that
through all those portions of the State the sanitary condition of which they
represent, the years 1860-61 were marked by the general prevalence of good
health. There was an absence of any wide spread, malignant epidemic, and
even the endemic maladies, and those of occasional occurrence, were more rare,
generally speaking, and milder in character than during the one or two years
preceding. It is true that in Philadelphia the bills of mortality would appear
to show an increase of disease during the year 1861 over that of 1860. This
increase is, however, more apparent than real. The seeming increase of mor-
tality in 1861 is in a great measure to be accounted for by the fact that the
registration of deaths has become much more accurate than formerly. It is
probable, however, that there has been an actual increase of mortality, from
various causes ; the influence of each of these has been slight, though in their
aggregate the influence they exercise upon the mortuary statistics is well
marked. Many of the three months' volunteers, and others of our soldiers, it
must be remembered, have returned to their homes to die, in consequence of
diseases contracted during their camp life.

Periodic fevers, though frequent in some parts of the State during the au-
tumns of 1860 and 1861, were by no means so prevalent as formerly. In portions
of Bradford County, intermittents prevailed to some extent complicated with
congestion of the pleura and lungs. None of these cases, we are informed,
terminated fatally.

Dr. Luden, in the report from Huntingdon County, remarks that intermittent
fever was formerly considered a regular yearly endemic of that portion of the
county, especially, which extends along the Juniata River and Pennsylvania
Canal, from two to three miles on both sides. About 1855 or 1856, from some
inexplicable cause, it suddenly ceased in that tract of country, and appeared for
one season about four miles more inland on both sides of the river. The disease
then disappeared, or nearly so. During 1861 a few cases of ague were met
with among the boatmen on the canal, who had probably contracted the fever
at some other place. In May, 1862, only two cases — a quotidian and a tertian,
were seen by Dr. Luden. The patients were both residents of the county, and
close to the canal. Cases of remittent fever, he states, were observed here and
there, in every direction, but comparatively few in number. Infantile remittent
was frequently met with.

From nearly every part of Montgomery periodical fevers have of late years
been disappearing to a very striking extent. Speaking of the Schuylkill region
generally, but more particularly of Plymouth and Whitemarsh valleys. Dr. H.
Corson remarks, that thirty years ago that section of country was inundated
with remittent and intermittent fevers. They continued to increase in preva-
lence up to 1832, when the cholera appeared and seemed to supplant them, or
at least in some particular manner to modify them, so as to render their occur-
rence less frequent and their character less severe for the few succeeding years.
They nevertheless continued to prevail to a considerable extent until 1849.
Since then they have gradually declined, until they have almost wholly disap-
peared.

480

Bibliographical I^otices.

[Oct

"I remember very well," says Dr. Corson, ''when the ague first spread itself
among the people along the Schuylkill Eiver, from Norristown to the Falls of
Schuylkill. It was attributed to the 'fresh dirt' thrown out in digging the
canals. That this was not the cause I think is likely, from the fact that more
fresh dirt is now thrown out every year, in the same neighbourhood, in-the dig-
ging of iron ore, than in making a short canal. The latter occupied only one
summer, the former is carried on annually. There has not been much change
in the agriculture of the region ; the proportion of woodland to farmland is also
nearly the same, so also the drainage. There was no swamp land then, when not
a house escaped the fever ; nor now, when not a house is visited. At Consho-
hocken, a large milldam, then kept well cleaned, is now nearly filled up, and
the water so shallow, that in summer time, if long without rain, nearly the whole
surface becomes a mass of drying mud and putrefying vegetation, and yet,
though a number of poor families live on its very margin, and the eastern margin
too, no fever, nor fever and ague prevails. Instead of these malarious affections
we now have occasional typhoid fevers and the other diseases which usually
prevail in places where formerly ague prevailed."

In Philadelphia C ount j intermittent fever has become of very rare occurrence,
remittents, also, are unfrequent diseases. This is owing mainly to the filling or
draining of the ponds of stagnant water which were so common in all the suburbs
— to the improvement of the river banks, the extension of paving and sewerage,
and the occupation by houses of the former vacant uncultivated lots.

Typhoid fever, though noticed in all the reports, does not appear to have been
so prevalent in any section of the State during the last two years as during
those immediately preceding. The disease appears to have been milder also
in its character.

Scarlet fever prevailed in nearly all the localities embraced in the reports pre-
sented to the Pennsylvania State Medical Society at its late session. It va-
ried very much in its character in different sections of country. In Beaver
County, among the villages near the mouth of the Beaver River, and in their
vicinity, some cases seemed to be modified by, or complicated with, diphtheria.
The general symptoms were those of scarlatina, while the affection of the
throat was that of diphtheria. In families of five or six children, one or two
would have the diphtherious deposit in the throat while the others would have a
severe attack of the fever unaccompanied by the disease of the throat.

Dr. Galbraith, of Perry County, says he had to treat only a single case of
scarlatina — the disease was well marked, mild in character, and ran regularly
through its several stages. It occurred in a delicate scrofulous girl, 13 years
of age. Scarcely had she recovered from the attack of scarlatina, when she
was attacked with erysipelas occupying the face. The attack was mild and
soon terminated favourably. The desquamation consequent upon the scarlet
fever went on as usual, and the patient was restored to her usual health.

In Philadelphia a pretty severe epidemic of scarlatina occurred in 1860, and
in 1861. In this latter year it produced a very heavy amount of mortality —
namely, 1190 deaths. The disease was generally of a low grade. The eruption
was slow in appearing and less marked than usual. The affection of the throat
was often the first symptom to appear, and of the longest continuance. Yery
many of the fatal cases were marked by an affection of the brain. In a few
cases the patients were seized with convulsions at the very onset of the disease,
on recovering from which they fell into an ataxic condition, or became comatose
and died within the first, or at furthest, the third day.

In some portion of nearly all the counties from which reports were received,
the occurrence of measles is noticed; in general the cases were few in number
and mild in character.

Dr. Winans, speaking of the disease as it prevailed in Beaver County, among
the villages at the mouth of the Beaver River, remarks, that the only peculiarity
observed in respect to it was the tendency to a reappearance of the eruption,
after it had apparently passed through its regular course. The usual symptoms
of measles were present until the subsidence of the febrile symptoms, when,
however, the eruption had almost disappeared, febrile symptoms would set in,
the eyes become red and watery, and the usual phenomena of the disease be-

1862.]

Transactions of State Medical Societies.

481

come again manifest. In from two to three days a well-marked rubeolous erup-
tion would reappear and pass through its regular course. The second or recur-
rent attack was in general more severe than the first.

Dr. G. W. Allison, of the same county, reports a case of measles in a new-born
infant. At the time of her confinement the mother was in the eruptive stage
of the disease, with high fever and violent cough. The labour was severe and
tedious. At birth the face and back of the infant were covered with an eruption
similar to that of the mother. It was more distinct on the next day, and had
then spread over the body and extremities, it now commenced gradually to dis-
appear ; first on the face. The infant had no catarrhal symptoms ; was feverish
and restless for a day or two. It finally did well.

In a portion of Perry County, Dr. Gralbraith states that a very severe epidemic
of measles prevailed during the latter part of the year, severe, so far at least as
symptoms were concerned, but not particularly fatal. The pulmonary organs
were those chiefly affected. Congestion and severe irritation of the lungs, and
sometimes bronchial inflammation, were certainly, according to Dr. G., the most
frequent complications of the disease. Quite a number of cases occurred in
persons near the adult age, and some in those considerably older, who asserted
that they had had previous attacks of measles.

While in the interior of the State, smallpox appears not to have prevailed
during the years 1860-61 to any very alarming extent ; in Philadelphia a very
large number of cases were constantly met with and still continue to be met
with. In 1861 the number of deaths produced by it was 758. Its occurrence
in Philadelphia is due mainly to the introduction of the contagion from abroad,
and the great neglect of vaccination and revaccination, more especially by the
poor and labouring classes, while its spread and destructiveness, when once it
had gained a footiug in the community, are to be referred to the crowding toge-
ther in badly ventilated and unclean neighbourhoods, of a population, a large
portion of which have their systems broken down from bad diet, intemperance,
exposure, etc.

A fact is recorded by Dr. Luden, of Huntingdon, showing how cautious we
should be to see that all sources of contagion are got rid of, before the removal
to a healthy house or locality of persons who have had the smallpox, even some
time after their entire recovery from the disease. A single case of the disease,
only, occurred in that borough, he remarks, during 1861. The patient was an
elderly female, who said she was vaccinated many years previously. Her grand-
daughter, three years old, had the smallpox in Philadelphia early in December.
She was removed to Huntingdon in the latter part of February. The attending
physician assuring her parents that there was no danger of her carrying with her
any contagion. Shortly after her arrival, the grandmother became ill. So soon
as it was ascertained that the attack was one of smallpox, the child was removed
to her grandfather's in the country, and he also, shortly after her arrival, was
attacked by the same disease. Vaccination was immediately resorted to, and
was effectual in preventing the further spread of the disease. The old lady died
on the fifteenth day of her illness, without having had any regular medical at-
tendance. The grandfather, who had never been vaccinated, recovered.

In the Philadelphia County report, the opinion is advanced that the suscep-
tibility of the human system to the vaccine influence is increased during the
prevalence of smallpox. We have seen nothing within the sphere of our obser-
vation which would lead us to such a conclusion.

It is remarked of the disease, as it occurred in Philadelphia, that unlike the
usual course of epidemics of that and other diseases — augmenting gradually
from their onset to the period of greatest height and intensity, and then gradu-
ally declining until they entirely cease — the smallpox, after having declined for
several months, suddenly underwent, towards the close of the year, without any
appreciable cause, a remarkable augmentation, and then, soon after, as sudden
a diminution.

Diphtheria prevailed throughout the State, differing in its extent and malig-
nancy in different localities. In Beaver County the disease assumed, in most in-
stances, a raild character, and terminated favorablv under a judicious treatment.
JS^o. LXXXYIIL— Oct. 1862. 31

482

Bibliographical Notices.

[Oct.

The most successful is reported to have been, mild laxatives ; the application to
the fauces, once in six or eight hours, of a wash composed of tincture of the mu-
riate of iron, muriatic acid and distilled water; three drachms of the first, one of
the second, and four of the third. For internal use, in a child three or four
years old, one drachm of the above mixture, in two ounces of water, given in
teaspoonful doses every two hours, with the addition, if there is great debility,
of one grain quinine to the alternate doses. In the intervals between the doses
of the above, a teaspoonful of a solution of two drachms chloride of potass in
four ounces of pure water. Spirits of turpentine to be applied to the throat
externally.

The disease was also of a very manageable character as it appeared in some
parts of Bradford County. Nothing especial is noted in respect to treatment.
The application of a mild solution of the nitrate of silver to the throat appears
to have been very generally practised. Gargles of salt and vinegar are com-
mended : externally, the application of strong spirits of camphor is the favourite
application of Dr. Horton. Internally, the chlorate of potass was given freely.
When symptoms of depression ensued, quinine and tincture of iron were given.
Twenty grains of the first in an ounce of the latter were administered in doses
varying with the urgency of the case.

In Bradford the worst cases of diphtheria occurred upon the hills and moun-
tains a mile or more from the river ; in the same localities where, ten-years ago,
agues were most frequent and obstinate. Yery few of the cases assumed a de-
cidedly asthenic character.

Dr. Luden, of Huntingdon, claims great success from the following treatment:
He first directs the administration of a saturated solution of muriate of sodium,
given warm and copiously until free emesis is produced. It will act also upon
the bowels. It may be repeated, if circumstances call for it, in the course of the
disease. After this, he gives internally a solution of chlorate of potass, or
diluted muriatic acid, and later muriated tincture of iron, alone or with quinine,
as the case may seem to require. Dr. Luden doubts the propriety of the appli-
cation of nitrate of silver to the diseased fauces ; he prefers, as a local applica-
tion, the saturated solution of muriate of sodium, with this he directs the whole
interior of the mouth to be well swabbed three or four times a day. Externally,
he applies around the neck a small bag filled with warm salt.

Dr. Corson speaks, from ample experience, in favour of cold water, iced water,
and ice externally and internally applied in cases of diphtheria and in the throat
affections of scarlatina. He pronounces it to be " more valuable than all the other
local means in use." And when "the commencing affection of the brain is
promptly met by the use of the same means to the head, in such decided appli-
cations as the case needs, we have a treatment which will seldom fail."

Dr. Galbraith, of Perry County, when speaking of his experience in the treat-
ment of diphtheria, very properly, in our opinion, repudiates the indiscriminate
application to the throat in this disease of nitrate of silver, as a practice cal-
culated to do, upon the whole, far more harm than is compensated for by the
advantages derived from it in the few cases to which it may be applicable.

A very full account of diphtheria, as it appeared in our midst, by the author
of the present notice, is comprised in the report from the Philadelphia County
Medical Society.

Dysentery is reported to have been epidemic, during 1861, in portions of
Bradford County. In one place, at least, where it had not prevailed for twenty
years before. Dr. Horton speaks very pointedly of the bad effects of opium and
astringents in its early stage. Dr. M. Miller, of Huntingdon, on the contrary,
describing a very inflammatory form of the disease which prevailed epidemically
in the northeastern portion of his county, attended with intense tormina and
tenesmus, discharges of bloody serum mixed with whitish flocculent matter,
and large flakes of false membrane; great tenderness of hypogastrium, difficult
micturition, etc., remarks, that the treatment which seemed most satisfactory
to him, consisted of " large doses of opium and ipecacuanha," to control, as far
as possible, the tormina and tenesmus. In the first stage, he gave nitre and
spirits of nitre freely, with veratrum viride, until the acute symptoms subsided.
As a laxative, he gave castor oil, or a saturated solution of Epsom salt and

1862.]

American Insane Hospital Reports.

483

elixir of vitriol, in doses, for an adult, of a tablespoonful of the first, with fifteen
drops of the last, every four or six hours until feculent stools appeared.

In Bradford County, erysipelas appeared to a limited extent. In one case,
Dr. Horton tells us it began as regular diphtheria. The face and scalp were
greatly swollen. The case terminated favorably. It was treated locally by the
tincture of iodine. Dr. H. remarks that, all during the winter of 1861-2, in
cases of wounds, a strong tendency was observed to erysipelatous inflammation.

In Perry County, Dr. Galbraith refers to several cases of erysipelas, which
fell under his care in 1861, one of which was of a very intense grade, and
attended with much suffering ; it commenced at the right ear arid extended over
the entire face and head. There was also severe affection of the throat, which,
for a time, rendered deglutition almost impossible. The other cases were not so
severe. They all recovered.

In respect to the connection between erysipelas and puerperal peritonitis. Dr.
Galbraith is so far aware of it, as, when the former disease is prevailing, to be
" ever on the watch for peritoneal inflammation in his puerperal cases." Dr. G.
has witnessed several epidemics of puerperal fever. The severest was in the
winter of 1849-50, and the spring of 1850. Preceding the epidemic, and in con-
junction with it, there occurred in his practice many cases of erysipelas of a
very severe grade, and every case of parturition he was called upon to treat was
followed by peritonitis of a very severe and frequently fatal character. In the
beginning of June, this state of things ceased, and for several years severe cases
of erysipelas ceased to be met with, and cases of puerperal fever were not observed
until towards the close of 1861, and the first four or five months of 1862, when
erysipelas again made its appearance, and during the same period cases of puer-
peral peritonitis were repeatedly met with. Though several of the cases were
prolonged, they were upon the whole mild and readily yielded to treatment.
Dr. G. does not pretend to explain the nature of the connection between con-
stitutional erysipelas and puerperal fever, but "that it does exist, and that
observation in the course of his practice establishes the correctness of such con-
clusion, is the solemn conviction of his mind."

Hooping-cough seems to have prevailed pretty extensively in Pennsylvania,
during the last two years. The uncomplicated cases all terminated favourably.
In Huntingdon, throughout 1861, and up to May, 1862, it was observed that in
several localities hooping-cough and measles alternated each other. At the
first the former taking the precedence, but later one or other would precede in
different families, but their disposition to alternate with each other was always
evinced.

The chief and most serious complications observed in cases of hooping-cough
were those of the lungs and brain, the first were the most frequent and fatal.

To several of the county reports are appended short Biographical Notices of
deceased members of the societies from which they emanate. D. F. C.

Art. X. — Reports of American Institutions for the Insane.

1. Of the United States Government Hospital, for the fiscal year 1859-60.

2. Of the Northern Ohio Lunatic Asylum, for the fiscal year 1860-61.

3. Of the Long View Lunatic Asylum, for the fiscal year 1859-60.

4. Of the Western Asylum of Kentucky, for 1861.

5. Of the Iowa Hospital, for the year 1861.

6. Of the Wisconsin State Hospital, for 1860-61.

7. Of the Neiu Hampshire Asylum, for the fiscal year 1860-61.

8. Of the Massachusetts Hospital, at Taunton, for the fiscal year 1859-60.

9. Of the Massachusetts Hospital, at Northampton, for the fiscal yearl859-60.

Before proceeding to an examination of the several reports with which we
have been favoured, we seize the opportunity thus early to present to our readers
the numbers of insane and idiotic persons in the several States, as reported in

484

Bibliographical J^'otices.

[Oct.

the National Census of 1860. We are enabled to do this through the kindness
of J. C. G. Kennedy, Esq., the able Superintendent of the Census, -who has fur-
nished us with a copy of these numbers in advance of publication.

States.

Insaxe.

Idiotic.

Free.

Slave.

Total.

Free.

Slave.

Total.

704

658

New Hampshire • . .

506

336

693

263

Massachusetts . . • •

2,105

712

Rhode Island ....

288

101

Connecticut .....

281

226

4,317

2,314

589

'589

'365

Pennsylvania ....

2,766

1,842

546

560

243

305

1,121

1,179

1,065

214

1,279

North Carolina ....

597

660

739

241

980

South Carolina ....

299

317

282

121

403

447

491

541

183

724

225

257

403

134

537

236

272

193

269

132

169

143

104

247

612

640

732

149

881

590

623

903

155

1,058

Ohio

2,293

1,788

1,035

907

683

588

750

770

447

510

152

176

251

333

Texas * .

112

125

164

201

289

283 '

283

257

456

Kansas ......

Total in States . . .

23,338

406

23,744

17,210

1,579

18,789

Territories.

District of Columbia . .

204

Total in Territories

255

Aggregate ....

23,593

406

23,999

17,286

1,579

18,865

1. In the report of Dr. Nichols, of the United States Government Hospital for
the Insane, for the fiscal year terminating with the 30th of June, 1860, it is stated
that —

"The hospital was, throughout the year, uninterruptedly healthy and pros-
perous. The admissions, both of public and private patients, exceeded those of
the previous year by nearly fifty per cent., and the ratio of recoveries to those

1862.]

American Insane Hospital Reports.

485

of tlie previous year was still larger. The accoramoclatious of the hospital have
not only been extended, but the personal comforts, and the occupations and
amusements of the patients, increased."

Patients on the 1st of July, 1859 .
Admitted in the course of the year
"Whole number ....
Discharo-ed. including deaths
Eemaining, June 30, 1860 .
Of the discharged, there were cured
Died

Men. "Women. Total,

138

152

230

106

167

Phi/sical condition of tJie patients at time of death. — "Chronic organic and
functional degeneration of the brain, irregular in character and extent, 6 ; ditto
with phthisis. 2 ; with epilepsy, 1 ; with carcinoma, 1 ; with paralysis, 2 ; exhaus-
tion of acute mania, 3 ; senile infirmity, 3."

"The average duration of the insanity, in the cases admitted this year, was
1.72 years, being thirteen per cent, less than that of any previous year."

Dr. Xichols thus writes upon the adaptation of hospitals to the needs of the
insane : —

Under the gentle pressure of the mild but firm discipline of a liberally ap-
pointed and faithfully conducted hospital, are alone to be found the special con-
ditions which, while they are most conducive to the restoration of the curable,
are equally calculated to smooth the path of those whose remaining years must
be dark if not sorrowful. Indeed, hospital life seems as normal, so to speak, to
the insane, as the institution of the family is to the social life of the sane. As
long as death is not always, nor most commonly, the immediate alternative to
recovery from insanity, institutions for the protection and comfort as well as
the cure of the insane, will continue to have a large number of confirmed cases
in their custody ; and to those who look most ardently for the happiest event of
hospital treatment, the presence of a considerable proportion of the less hopeful
class of inmates should not be deemed objectionable. To many of the quiet,
long-domiciled patients in a hospital, its discipline has become a passive and
often an agreeable habit, and as new patients naturally imitate the ways of old
ones, the influence of the latter class in promoting a ready and cheerful acqui-
escence on the part of new comers in common habits of order, occupation, and
self-constraint, is often material and salutary."

It is doubtless generally known that this hospital, like some others of the
public buildings of the general government, has been erected piecemeal. A
section of less than one-third of the whole was completed and opened for pa-
tients before any part of the rest was begun. It is gratifying to learn from the
report before us that the last portion is under roof, and "the plastering and
trimming of the interior somewhat advanced," while "the centre and contiguous
sections of the wings have been entirely completed, furnished, and fitted up, and
are now appropriately occupied throughout."

The bnildings having been brought thus nearly to completion, the opportunity
presented by this report is seized for the purpose of giving a somewhat detailed
description of the whole establishment. The text is illustrated by five large
lithographic prints, the first of which is a topographical plan of the grounds ;
the second, a ground plan of the buildings; the third, a perspective view of the
main edifice; and the fourth and fifth, details of construction and furniture. As
this hospital is a national work, we quote at length the general description of it.

"This establishment comprises —

"1. A tract of one hundred and ninety-five (195) acres of land, situated on
the southeast bank of the Anacostia Eiver. It is nearly due south from the
United States capitol, and about two miles from it in a direct line. It is the
most prominent part of what has been known ever since the settlement of the
country as the St. Elizabeth tract. Considered as the site of an institution for
the insane. I think it not extravagant to say that it combines special advantages
that are not probably exceeded in any other one tract in the whole world. It
is perfectly healthy. The site of the'hospital edifice commands a panoramic

486

Bibliographical Notices.

[Oct.

view of tlie entire District, and of an equal extent of country in Virginia,
including the city of Alexandria, and, incidentally, of the navigation of the
Potomac, and the ordnance experiments, launches, and other conspicuous ope-
rations at the navy yard and arsenal. Who can tell how many hours, otherwise
sorrowful or dull and tedious, will be more or less relieved by the varied scenery
and the teeming incidents of this grand panorama, which will often steal upon
the notice of those who would repel personal sympathy and attention.

"In another part of this report I have alluded to the admirable natural adapta-
tion of considerable portions of this tract to the purpose of pleasure grounds
for the insane, and need not repeat what I have there said; but may add that
it comprises every variety of soil and exposure, and affords, fresh and abundant,
the luxuries of the garden, the farm, and the dairy.

"When this tract of land came into the possession of the government, about
one-half of it, or one hundred acres, were under cultivation. Since that time
its productiveness has been increased at least fifty per cent., and about twenty
acres have been reclaimed from the forest, and put under cultivation — about the
same number that have been appropriated to the site of the buildings, and the
grounds and yards for their immediate accommodation. It is thought that the
original forest may be ultimately reduced to fifty acres, and that about forty-five
acres will be appropriated to the buildings and to drives, walks, ornamental
trees and shrubbery. The former will still afford a range for stock, and the lat-
ter, the supply of hay necessary in the stable-feeding. The lesser channel of
the river washes the hospital shore, and bears to its own wharf, at reduced cost,
its heavy supplies. It is in accessible proximity to the city, from which it is
separated by a barrier to the encroachments and annoyances of a populous town.
It has an unfailing spring of pure soft water, and if more water than the spring
supplies should be needed for ornamental or agricultural purposes, resort can
be had to the river, and various and efficient are the means for raising water to
any required height. An accurate topographical survey of the grounds of the
hospital is appended to this report, to which I beg to refer for a clearer compre-
hension of the special merits of this site.

"2. A principal hospital edifice and two detached lodges. — The wings of the
main building and the lodges contain two hundred single chambers and thirty-
two associated dormitories; fourteen drawing-rooms, twenty-four dining-rooms,
twenty-two bath-rooms, twenty-eight water closets, fifty-seven clothes-rooms and
closets, four sewing-rooms, two coal vaults, two servants' dining-rooms, and in
immediate prospect, two bowling saloons, and one ice and preserving cellar, and
will accommodate without putting more than one person in a bed, or one bed in
a single chamber, or more than six beds in each of the four largest associated
dormitories, or more than four in each of the remaining twenty-eight, three hun-
dred patients — two hundred and sixty whites, and forty blacks — and thirty-six
personal attendants. It will be remembered that the room required by the
insane is about double that usually allotted to the sick with other than mental
disorders. A general hospital of this size would receive at least five hundred
patients. The number of insane that different institutions for their custody and
treatment will comfortably accommodate, depends upon other circumstances
than their relative size, and those circumstances are different at different times
in the same institution. For example, this institution retains the custody of
most of its incurables till their death, and this class will increase in actual num-
bers, if not in proportion to the whole number under treatment. It will include
many quiet, passive persons, to whom a much closer aggregation than that con-
templated in the statement of the accommodations of the hospital, already made,
would be in nowise objectionable. If we suppose that this class will, in the
long run, average one-third of the whole number under care, I think that the
maximum accommodations of the hospital will prove, in practice, to be one-sixth
greater than what may be called its rated capacity, and that three hundred and
fifty patients will be treated very comfortably. If, on the other hand, this hos-
pital should, like some institutions of this character, be obliged to cast off its
incurables and select the most promising cases from among a surplus of pressing
applicants, its proper accommodations would be one-sixth less than its rated
capacity.

1862.]

American Insane Hospital Reports.

48t

''The centre of the main edifice contains, above the basement, twenty-five (2.5)
rooms, ranging in size from 21 ft. 4 in. by 16 ft. 6 in. to 20 ft. 3 in. by 19 ft. 10
in., and one chapel and lecture room 60 ft. 10 in. by 50 ft. 9 in., thirty-two closets,
twenty-five, 6 ft. by 10 ft., and eight 3 ft. by 6 ft. ; four water closets, each 6 ft. by
10 ft., and one bath-room of the same size; and, in the basement, two kitchens,
one 43 ft. 9 in. by 19 ft. 11 in., and one 20 ft. 3 in. by 19 ft. 10 in. ; one bakery,
43 ft. 9 in. by 19 ft. 11 in. ; one dairy-room, 23 ft. 2 in. by 11 ft. 9 in. ; and three
store-rooms, two 20 ft. 3 in. by 19 ft. 10 in., and one 21 ft. 4 in. by 16 ft. 6 in.

"This building is the material centre of the establishment, as well as of its
administrative authority and domestic economy. It contains the reception
rooms, business offices, private rooms of the superintendent and his immediate
assistants, and the kitchens and store-rooms.

"3. The outbuildings of the hospital. — They comprise (1), connected but dis-
tinct stable accommodations for 12 horses, 32 neat cattle, 1 00 swine, and 200
fowls, including lying-in, calve, tool, grain, carriage, slaughter, and feed-rooms,
a root cellar, large fodder lofts, approved machinery, propelled by steam power,
for cutting fodder, crushing and grinding corn in the ear, and for grinding clean
grain of all descriptions, and steam kettles for cooking food for stock; and (2),
in another building, an extensive laundry, one engine, one engine and pump, one
boiler, one fan, one gas and one machine room, and a vault holding 500 tons of
coal. The laundry occupies the whole of the second story, and has a drying
yard attached to it. It is fitted up with a centrifugal wringer, a Shaker washing
machine, a power mangle, a steam and fan drying room, and all the best of the
modern improvements. The power engines, steam pumps, fan, boilers, and gas
works, are each the best of its kind, or were certainly intended to be. The
exterior and partition walls of both of these buildings are built of brick, and
their entire construction is throughout substantial and durable.

"The ground plan of the main edifice has been appropriately denominated an
echelon. It is a modification of what is known in this country as the Kirkbride
or Trenton plan, and is thought to embrace peculiar advantages in respect to
classification, light, and spontaneous ventilation, and in presenting the broken
outline of a castle or villa. The facade of the building is called the collegiate
gothic style, and is thought to be appropriate, and also highly effective, in view
of its plainness and the cheapness of the materials in which it can be represented.
Mechanically speaking, all the buildings of the establishment are believed to be
as substantial and durable as, at the average high prices of materials and rates
of wages in the District since they were commenced, could be built for their cost.

"Every effort has been made to make the internal finish of the house and its
furniture and conveniences tasteful and homelike, and to adapt them in all the
wards to the habits and wants of the insane, and in each ward to the comfort
and safety of the particular class it is designed to accommodate.

"The heating of the building is by the hot-water circulation; the ventilation
is by a fan or blower. The arrangements for both were devised at the hospital,
and put up without the aid of a special engineer, and experience has shown that
they are efiective in promoting the comfort and health of the inmates of the
house."

We complete our extracts from this report with the author's appropriate
remarks upon the character of the institution.

"A government establishment situated in or near the capital of the republic,
whether scientific or benevolent in its objects, is a representative institution.
That character is inseparable from its conspicuous position. It also arises from
the universal and just expectation that all institutions and appurtenances of the
general government of a great nation will be complete, according to the know-
ledge and appreciation of their several objects enjoyed by the representative or
ruling people of the country. If this institution is, in truth, to ever so small
an extent, an exponent of American knowledge and philanthropy, its position
is, in that respect, a highly responsible one. It will have some influence upon
the character of the other similar institutions of the country, and that influence
ought, in time, to be large and good. It will have its weight, however small, in
determining the estimate our own people will form of the character and benefits
of their own government, and it will also affect the judgment that the citizens

488

Bibliographical Notices.

[Oct.

or subjects of other countries and governments, travelling or sojourning in tliis
country, will form in respect to the character of American institutions, and the
practical merits of the American form of government.

"A sense of this responsibility has been kept steadily in view, and we believe
that every succeeding year has l3een characterized by an increasing progress in
that pursicit of perfection which we have sought to make the cardinal and ani-
mating principle of the management of the hospital,"

From observation during a recent visit to this institution, we are enabled to
add our testimony to the progress mentioned, as well as to state that the build-
ings appear to have been erected with a constant view to convenience, perma-
nence, good taste, and liberality of space, combined with a judicious and wise
economy.

2. The report of the Northern Ohio Lunatic Asylum ior the official year
terminating with the month of October, 1861, contains the following numerical
results : —

Men. Women. Total.

Patients at the beginning of the year . . 64 71 135

Admitted in course of the year ... 67 64 131

Whole number 131 135 266

Discharged, including deaths .... 59 66 125

Remaining at the end of the year . . .72 69 141

Of the discharged, there were cured ... 31 36 67

Died 3 3

Died of apoplexy, 1 ; epilepsy, 1 ; consumption, 1 .

"Hereditary predisposition existed in twenty-eight of those admitted during
the year, and the suicidal propensity was evident in thirty-eight."

Our readers are aware that, in Ohio, the whole expenses of the State Benevo-
lent Institutions are defrayed from the treasury of the commonwealth. In
allusion to this fact, Dr. Kendrick says : "Not a few entertain the erroneous
idea that our State institutions must necessarily be pauper establishments. On
the contrary, our citizens are equally taxed for their maintenance and equally
entitled to their favours. The benevolence of the people has opened wide the
doors of their public charities, not to debar the intelligent, the wealthy and the
refined from participation in their benefits, but on the ground of a common
humanity, to place those benefits within the reach of all ; and as this is a com-
mon bounty, its recipients, who are joint contributors to it, should find in it
ample resources to meet the wants of all. Until this is done, our benevolent
institutions will continue to fall far short of their true mission."

3. The new buildings for the Hamilton County (Ohio) Asylum have been
completed, and put into operation under the title " Long View Lunatic Asy-
lum.'' The superintendent. Dr. 0. M. Langdon, was appointed in November,
1859 ; the first patient was received on the 21st of February, 1860 ; and be-
tween the 26th of March and the 3d of May, of the latter year, 296 patients
were transferred to it from the old establishment. Twenty-three patients were
also removed to it from the hospital at Dayton. The report is dated October
31st, 1860, and consequently the numerical record of patients includes a period
of but about eight months.

Men. Women. Total.

Patients admitted
Discharged cured

" improved .

" unimproved
Died ....
Remaining Oct. 31st, 1860

The report is chiefly occupied by a descriptive account of the establishment.
The Board of Trustees, in their fixed report, say: "To the honour and credit of
Hamilton County be it said, that to her beneficence we are indebted for the
largest, best constructed and arranged Insane Asylum in the country;" and

206

216

422

151

183

334

1862.1

American Insane Hospital Reports.

489

Dr. Langdon asserts that " wlien all the improvements in the house and grounds
are finished, we shall have an institution unsurpassed by any in the country for
beauty of location, conv^enience and spaciousness of building, and general per-
fectness of appointment,

" The lot upon which the building stands contains thirty-eight acres. * *

" The building is beautifully situated on a ridge, overlooking the valley of
Mill Creek, above which it is elevated about one hundred feet, thus obtaining
an extensive and beautiful prospect in almost every direction, not only from
the house, but from the grounds around it. It is about seven miles from Cin-
cinnati, and very easy of access. It is built of brick, is six hundred and twelve
feet long, and consists of a centre building, five stories high, surmounted by a
dome, and two wings, three stories high, each intersected by three cross-build-
ings, two of which are four stories high, one of them surmounted by a dome,
smaller, however, than the one on the main building."

There are wards for pay-patients in the fourth story of the central edifice.
The wings are wholly devoted to paupers.

" The iron stairways in the house are not only convenient for the passage of
patients from one part of the house to another without bringing them to the
pubhc stairways, but in case of fire they furnish a ready and safe means of
egress for all inmates. The wards are shut off from each other by double doors,
preventing any noise in one being heard in the next. The floors are all laid in
cement, which serves an excellent purpose in deadening sound, and in connec-
tion with the abundant supply of water, is almost perfect protection against
fire. Each ward contains a bath-room, pantry, wash-room, and water closets,
supplied with hot and cold water from faucets, with self-acting valves, to pre-
vent waste of water by the inmates. Each contains also an elevator, drop or
chute for soiled clothes, and one for dust, which reaches to the basement. The
cross buildings of the wings are all, except the two at the extreme ends in which
the strong rooms are located, one story higher than the rest of the wings, and
the two next the main building are surmounted by domes. The upper stories
of these are devoted principally to convalescents, and contain the amusement
and reading rooms."

The building is lighted by gas, and ventilated through a large air duct in the
cellar which opens into a chimney 125 feet in height, the common escape from
the fires in the several departments of domestic labour. An adequate supply of
water is furnished, through a forcing pump, from the neighbouring canal. The
house contains "nearly six hundred rooms, fifty-six water closets, six thousand,
one hundred and seventy-eight feet of water pipe, three hundred and fifty-six
cocks, and five hundred gas burners."

4. The report for 1859 of the Western Lunatic Asylum of Kentucky was
the last which has heretofore come to our hands. We still have none for the
year 1860 ; but we learn, from other sources, that in the early part of December
of the year last mentioned, the building of that institution was totally destroyed
by a conflagration, the origin of which is to be attributed to a defective chimney.
With one exception, the patients were all saved. They were furnished with
temporary shelter in the public buildings and some of the private dwellings of
Bfopkinsville ; but the principal ofiicers, of whom Dr. Montgomery is the chief,
were so much engrossed in their laudable eff'orts to save the patients, that their
own effects were destroyed.

By the report in hand, it appears that the building is in process of reconstruc-
tion. We infer, also, that most of the patients were not returned to their former
residences, but are retained in some of the halls which have been rebuilt, or in
temporary receptacles.

Men. Women. Total.

Patients on the 1st of January, 1861 .
Admitted in the course of eight months

Whole number

Discharged, including deaths
Remaining, September 1, 1861
Of those discharged, there were cured
Died

161

173

138

490

Bibliographical Notices.

[Oct.

The very small number of admissions," writes Dr. Montgomery, " is owing
to the fact that, since the fire, our room and means of accommodation have been
restricted ; indeed, all the wards, particularly those for females, being constantly
crowded, too much so for the comfort and even safety of the patients, especially
during the hot weather of summer. Most of the few admitted had been re-
turned to their friends immediately after the fire, with the understanding that
they might be sent back if their condition should seem to require it." * * *
To those "who know and can consequently appreciate the difficulties under
which the institution has recently laboured, the number who have eloped (7) will
not appear large. The cabins for the males cannot readily be made so secure
as to prevent frequent escapes at night."

The terrible calamity of the conflagration, the death of the steward, the re-
signation of the matron, and the loss of most of the experienced attendants,
when considered in connection with their consequences, constitute a melancholy
chapter of experience for Dr. Montgomery, in the short space of one year of
hospital life.

5. About seven years ago the General Assembly of Iowa made its first appro-
priation for the erection of a State Hospital for the Insane. After delays not
unusual in enterprises of the kind, the centre and one wing of the principal
building were completed, and opened with appropriate ceremonies, on the 6th
of March, 1861. The hospital is at Mt. Pleasant, and is under the superintend-
ence of Dr. R. J. Patterson, formerly of the Indiana State Hospital, and, still
later, of the Asylum for Idiots in Ohio. His experience is large, and his ability
unquestioned. We quote from his description of the establishment now under
his care : —

" The hospital farm consists of 173 acres of fertile land, about one-half of
which is sparsely timbered and beautifully diversified by hill and valley. The
other half is what is termed rolling prairie.

" The building, which is of the Elizabethan style of architecture, consists of
a stately central structure, and wings on either side, tastefully grouped in the
quadrangular ^orms. The central portion is four stories high, and all other
parts three stories high above basements. The walls are all of solid cut stone
masonry, lined on the inner side with brick. The roof covering is of heavy
galvanized iron.

" In the central building, which is 90 by 60 feet, and four stories high, are the
public offices of the Superintendent and his assistants, the Steward's and the
private rooms of all resident officers. It has also a rotunda 49 by 57 feet, in
which is a splendid double stairway reaching to the top. It is surmounted by
a beautiful tower, the top of which is 137 feet from the ground. The six wings,
three on either side, are for the special use of patients, and are each respectively,
114, 151, and 131 feet in length by 40 feet in width, all three stories high above
the basements. They are agreeably diversified by bay windows, projections,
and recesses, and give an entire front of 512 feet. Two cupolas rise 90 feet from
the ground over these wings, and serve a practical use as ventilators as well as
ornaments. At the extreme end of these wings are return- wings, each 131 feet
deep by 40 feet wide, giving the structure its quadrangular form. Also, there
is one central wing, extending from the rear of the central building, 115 feet
deep, three stories high, in the basement and first stories of which are the
kitchen, bakery, dining-rooms, store-rooms, and other domestic offices. In the
second and third stories is a beautiful chapel 38 by 50 feet, with 20 feet ceiling,
in the rear of which are numerous lodging-rooms for domestics.

" In the whole establishment there are 425 rooms, great and small, exclusive
of basement rooms. It contains 1,100 windows and 900 doors. A walk around
the outside walls is a half mile, and a walk all over its halls about one mile in
length. It required 120,000 square feet of galvanized iron sheeting to cover the
roof. In the basement is a railroad one-eighth of a mile in length, with iron
rail, upon which a hand car carries the food from the central kitchen to dumb-
waiters beneath all dining-rooms. The buildings are designed for the liberal
accommodation of at least 300 patients, with all needed officers, attendants, and
assistants to take care of them.

1862.]

American Insane Hospital Reports.

491

*' The entire establishment is warmed by steam, and all machinery for elevating
water, for forced ventilation, for washing and wringing clothes, is driven by
steam power. Steam is also liberally used for heating water for baths, and for
cooking. Galvanized iron pipes carry hot and cold water to every part. There
are 70,000 feet, or about 12 miles, of iron pipe connected with warming, lighting,
and the distribution of water. Iron tanks, whose aggregate capacity is 14,000
gallons, have been placed in the central attic, and a brick cistern, cylindrical in
form, whose capacity is 3,000 barrels, has been placed under ground.

"A rotary fan, fifteen feet in diameter, with eight feet span, driven by steam
power, secures a forced ventilation. The wash-house and laundry are furnished
with a large David Parker washing-machine, a rotary patent wringer, and a
mangle, all propelled by steam. The buildings were completely piped through-
out for gas before plastering the waWs, and a gas-house will be erected and gas
lights introduced during the next year, from an unexpended appropriation for
that purpose.

" Having examined nearly all of the best hospitals in the United States, and
having experienced more than ten years of hospital life, I am enabled to speak
with much assurance in regard to the excellence of our buildings and fixtures.
They are doubtless the most permanently built in every part and among the
most extensive of any in the country. They seem to have been erected for all
time. No one portion has been slighted, but everywhere are abundant evidences
of enlightened economy and skill, faithfully applied.

" The furniture is in keeping with the building. The language of the Iowa
State Medical Society, who visited the hospital, declares, ' everything excellent —
nothing superjluous.' "

The report bears the date of December 1, 1861, and hence covers a period of
a few days less than nine months.

Patients admitted

Discharged, including deaths
Eemaining, November 30, 1861 .
Of those discharged, there were cured
Died

Men.

Women.

Total.

170

140

Causes of death. — Exhaustion from chronic mania, 5 ; consumption, softening
of the brain, typhoid fever, and congestion of the brain, 1 each.

It is a noteworthy fact, that of the 170 patients 70 were between the ages of
20 and 30 years, and only 43 between those of 30 and 40 ; the number in the
former decade being nearly twice as large as that in the latter. The proportion
is larger than at the institutions among the older populations of the more early
settled States.

The subjoined extract, coming as it does from authority based upon extensive
observation among both idiots and the insane, is of no small importance.

"Although the period of childhood furnishes, comparatively, few cases of
insanity, I am led to believe, from an examination of the history and condition
of inmates of idiot asylums, that insanity is more common among children than
has generally been supposed. Many of those inmates show, or have shown,
signs of insanity rather than idiocy. In many cases the insanity in these young
subjects has been overlooked, and becoming chronic and assuming the form of
dementia, these persons have been regarded as idiots, and have been very pro-
perly placed in an appropriate institution for their improvement.

" The cases of insanity in children that have come under my notice have oc-
curred, as in adults, more frequently among those who have inherited a predis-
position to mental unsoundness, or who possess highly nervous temperaments,
and are exposed to circumstances favouring the development of mental disease.
Though not of a low grade of intelligence, they have marked peculiarities, are
very nervous, highly excitable, subject to uncontrollable fits of passion, have
strange caprices, and submit but poorly to established rules."

Although the battle against the lancet has dwindled into a mere guerilla
warfare, and most of the bleeders have become seceders, we consider it import-
ant that the last petty enemy should be chased and conquered, and consequently

492

Bibliographical Notices.

[Oct.

give a place to Dr. Patterson's, wherein lie may exercise his generalship in the
cause.

"Bleeding, at the present day, is scarcely resorted to, even in private prac-
tice, and much less in public institutions, where the physical status in almost all
cases, when admitted, is found to be greatly helow par. No combination of
symptoms in any case thus far admitted, could have justified us in resorting to
bloodletting. Raving mania can be more permanently controlled by the use of
the warm bath, cooling applications to the head, warm foot-baths, mild cathar-
tics and anodynes, and, in certain cases, by stimulants. Bleeding may quiet a
paroxysm of mania temporarily, but the excitement is apt to return with greater
fury, while the system is less able to bear it than before. Bleeding, therefore,
does not accomplish the desired object, but, on the contrary, it impoverishes the
blood, and reduces the strength, without diminishing permanently the nervous
excitement. A few cases only seem to have suffered from too free depletion
before admission to this institution, and these have required the protracted use
of tonics and good diet to repair the evil. The use of blisters, setons, and
moxas, together with drastic purging and emetic tartar, may go with bleeding.
All these are obsolete, in this latitude and climate."

6. Dr. Clement, in his report of the Wisconsin State Hospital for the Insane,
occupies but three pages, confining himself to such subjects alone as he "deems
to be of interest to the guardians of the institution, and to the people of the
State, its willing and able supporters."

The hospital was opened on the 14th of July, 1860 ; the first subsequent
report, which was noticed in our issue for July last, was dated December 16,
1860; and the second report, now before us, bears the date of October 1, 1861.
The whole period since the opening being but 14^ months, the numerical record
from the beginning is included in the following statistics : —

Causes of death. — Phthisis, 3 ; softening of the brain, 2 ; maniacal exhaus-
tion, 2 ; exhaustion from puerperal mania, general paralysis, epilepsy, and dys-
entery, 1 each.

"The case of dysentery was an isolated one. There has been no prevailing
sickness in our household. The general health of our patients could not have
been better. Our location is apparently very healthy, our ventilation is as per-
fect as has ever been attained, we have furnished an abundance of nourishing
food, and have given constant and untiring attention to the cleanliness, exercise
and diversion of those under our charge. We have therefore expected, and
should have been sadly disappointed not to realize such results."

"Our patients have enjoyed a remarkable amount of out-door exercise during
the past summer. Many have willingly aided in clearing up the grounds, work-
ing the farm, the vegetable and flower gardens, and performing any desired
labour. Others have enjoyed fishing upon the lakes, thus obtaining not only a
very pleasant and healthy kind of exercise, but also an agreeable variety of food
for their tables. We have also a large and very safe sail-boat, which has proved
to be one of the most useful things connected with the institution, affording a
rare and very pleasing variety of exercise and entertainment. It will never be
used by the patients, except under circumstances that insure positive safety.
We have a flower garden in front of the building, that seems almost the result
of a miracle, considering the short time in which it has been produced. Bou-
quets from this are constantly on the tables throughout the house, and the more
quiet female patients are frequently allowed to walk in it and pick flowers for
themselves.

"During the past winter we had frequent dancing entertainments and social

Patients admitted . . . .

Discharged

Remaining

Of those discharged, there were cured
Died

Men. Women. Total.

72 73 145
21 21 42

51 52 103

16
11

1862.]

American Insane Hospital Reports,

493

gatherings. Eeligious services are held in the chapel during the Sabbath, which
are gladly attended by about one-half of the patients, who conduct themselves in
an orderly and quiet manner. We have a hired billiard table, which is in almost
constant use during the cold season. "We very much need a library.. These
means of entertainment and exercise are not mere luxuries, but actual neces-
sities, of which the State cannot afford to allow the institution to be destitute."
Another section of the hospital is in course of construction.

7. The report for the fiscal year 1860-61, by Dr. Bancroft, of the New Hamp-
shire Asylum for the Insane, is unwontedly short, and its contents limited
almost exclusively to statistics and the material improvements of the year.

Men. Women. Total.

Patients on the Ist of May, 1860 ... 95 89 184

Admitted in course of the year .... 48 58 106

Whole number 143 147 290

Discharged, including deaths .... 55 39 . 94

Remaining May 1, 1861 ..... 88 108 196

Of the discharged, there were cured ... 19 15 34

Died 12 4 16

Although at some former period we have mentioned the disposition to com-
pare the statistics of the institutions for the insane, irrespective of the many
conditions and circumstances by which they are modified, we think it proper
again to recur to the subject. The results of a comparison so made are detri-
mental to some institutions, too favourable to others, and. unjust to all.

The New Hampshire Hospital has been in operation nineteen years, and
hence it might be expected that a very large percentage of the admissions would
be of cases of short duration, and consequently susceptible of restoration; but
the subjoined extract shows that such result has not yet been reached.

" Of all admitted during the last year only fifty-six were recent attacks of
insanity, while fifty, or nearly one-half, were persons in whom the disease had
existed for longer or shorter periods ; in most more than one year, and in many
several years ; and nearly all of the latter class had passed the period which
affords much hope of recovery."

With such material to work upon, it is unreasonable to suppose that the pro-
portion of cases can be large.

The next extract shows that with but little acute disease in the hospital, a
combination of circumstances, from some of which many institutions are exempt,
may swell to a remarkable extent the proportion of fatal cases.

" Of the'sixteen deaths, six were aged persons who had long been in the house,
worn out at last by chronic insanity. Two were old residents in the house, one
•dying of apoplexy, and the other of paralysis. Another, a resident of many
years, died of consumption. The others were here but short periods. One, a
man over eighty, broken by intemperance, in a state of senile dementia, died in
twenty days after admission. A woman, brought in a state of extreme prostra-
tion from ill-health and wounds received in attempts at suicide, died exhausted
on"the fourteenth day. Another aged lady, who was brought in the last stage
of senile dementia, died on the tenth day. The four remaining ones — who died
of maniacal exhaustion — lived severally, nineteen, eleven, ten, and five days after
admission."

It gives us pleasure to exhibit, in the words of the report, the progressive
efforts in the modern system of moral treatment.

"The desirableness of increased facilities for the occupation and amusement
of patients has been steadily kept in view, and additions made as fast as the
means at command would allow. A magic lantern with coloured views has been
procured, and was used during last winter. Even from the small number of
representations we were able to exhibit, the patients have derived much plea-
sure. A new and commodious bowling room has been built for the female
patients, which will furnish them much healthful exercise as well as amuse-
ment."

494

Bibliographical IN'otices.

[Oct.

A large addition to the central edifice of the hospital was erected in the course
of the year.

8. Although Massachusetts has three large State hospitals for the insane, it
appears that there is need of still another. Dr. Choate, of the hospital at
Taunton, says, in his report for the fiscal year 1859-60, that the establishment
under his care was intended for the care and cure of two hundred and fifty pa-
tients, and the space allotted was such as was considered by the best authorities
necessary for the comfort and well-being and improvement of that number ; yet
the actual number accommodated has gradually progressed beyond that limit
until, in July, 1860, it reached 392. He then advises that the number be limited
to 400.

Died from phthisis, 17 ; maniacal exhaustion, 7; softening of the brain (para-
lysie gen6rale), 5; chronic mania, 4; paralysis, 3; apoplexy, 2 ; marasmus, 2;
diarrhoea, 2 ; fever, 1 ; anaemia, 1 ; erysipelas, 1 ; suicide, 1 ; haemoptysis, 1.

In this report the term "maniacal exhaustion" is limited to recent cases.
"This is," writes Dr. ^Choate, "the ordinary termination of such acute cases as
result fatally. Intens'e and long-continued excitement, inordinate and unhealthy
exaltation of the feelings and sentiments, constant agitation of mind and body,
and the continued sleeplessness, which are attendant upon acute mania, must
inevitably, by one of the plainest laws of nature, be followed by corresponding-
depression and exhaustion. This, in ordinary cases, is not so severe as to en-
danger life, but is the gate through which the patient passes to convalescence
or to dementia. But occasionally, when the excitement is high and prolonged,
and the vital powers weak, the reaction is so complete and extreme, that the
patient never rallies from it, but sinks rapidly till death closes his sufi'erings."

"More than thirty per cent, of the deaths since the opening of the institution
have been from phthisis. This is probably by no means in consequence of
persons with a scrofulous diathesis being more liable than others to mental dis-
ease, but arises from the fact that the development of scrofulous diseases, of
which phthisis is one form, is favoured by any cause which lowers the general
system and weakens its tone."

The following extracts are from the remarks upon the causes of insanity : —

"In reviewing the table of causes, one cannot help being struck with the
large proportion of cases which are self-induced. And the consideration of
this class will be especially useful if it should lead any to the avoidance of
practices and habits which are pregnant with danger. Four hundred and
twenty-one out of eleven hundred and ninety-five cases in which the cause was
known, were produced by acts and habits over which the individual has full
control. But these are only the acknowledged cases of unfortunate habits,
only those where they are so obvious and excessive, that they are freely con-
fessed either by the individuals or their friends. In how many more the true
cause is concealed, from shame and dread of disgrace, every student of human
nature can judge for himself."

" In its threefold operation upon the physical system, upon the intellectual
functions, and upon the moral sense, it may well be questioned whether habitual
stimulation, directly and indirectly, is not the source of more mental disease
than all other causes of insanity combined. Acting upon the body, it is the
immediate cause of many cases of mania and dementia, of nearly all the instances
of softening of the brain, of epilepsy, paralysis, and diseases of the digestive
organs, which, in their turn, react upon and overthrow the mind. Acting upon
the mind, its tendency is to weaken the reasoning faculties, and undermine the
judgment, inducing unwise business transactions, unfortunate social connections,

Men. Women. Total.

Patients on the 30th Sept., 1859
Admitted in course of the year
Whole number ....
Discharged, including deaths .
Eemaining Sept. 30th, 1860
Of those discharged, there were cured
Died

165 176 341

130 115 245

295 291 586

105 120 225

190 171 361

54 47 101

25 22 , 47

1862.]

American Insane Hospital Reports.

495

loss of property, and the mental disorders wMch these occasion. Acting- upon
the heart, it perverts the moral sense, and weakens the powers of resistance to
temptation, leading to domestic unhappiness, ill-treatment of friends, and in-
dulgence in other fatal habits, and these, in turn, contribute their share to the
numbers of the insane."

In regard to the character or form of mental disorder, it is said : —
" The prevailing popular idea, that many persons are insane only upon one
subject, though apparently correct, is unquestionably fallacious. The promi-
nence of a single delusion or of false ideas upon one class of subjects, should
prompt us only to a deeper investigation, which will almost invariably disclose
to us a general impairment of the intellectual faculties."

As an illustration of the correctness of this view, the following case is
mentioned : —

" A young lady of more than ordinary native intelligence and of considerable
cultivation, is firmly possessed of the idea that her hip is dislocated, and that
she is helpless. So prominent and urgent is this delusion, that at first sight
one would be inclined to place the case in the class of monomania, but further
examination discloses other not less curious but more latent delusions."
We close our notice of this report by the following extract : —
" A single remarkable case occurring during the year is worthy of special
mention. It is one of complete recovery after eighteen years of disease. Such
cases are mentioned by some of the French writers, but they are alluded to
merely as remarkable and exceptional cases, and are seldom seen or recorded
even in hospital reports, which cover annually such an immense number of
instances of disease. The case was one of periodical mania, of excitement
alternating with depression, not differing materially from many of the same
class, which are at all times inmates of the hospital. The patient has now been
perfectly well for ten months, and occasionally writes to her friends whom she
has left here. It should lead us to look with some degree of hope upon many
cases which have long been given up even by their friends."

9. In his report for the official year 1859-60, Dr. Prince, of the Massachusetts
State Lunatic Hospital, at Northampton, in reference to the character of his
patients, says : " Our numbers have largely increased, and the records show that
a large proportion of this increase is composed of State paupers, a little less
than fifty per cent, of the admissions being from this class. As they are mostly
incurable cases, and of a character that prevents the possibility of their being
cared for in an institution of a different character, they will be permanent resi-
dents, and as the increase goes on, the institution will partake more and more of
the character of a retreat for incurables."

Died from maniacal exhaustion, 14 ; phthisis, 8 ; apoplexy, meningitis, peri-
tonitis, suicide, and injury from a fall, 1 each. The term "maniacal exhaustion,"
as here used, undoubtedly includes, not only those cases of recent insanity, the
violence or severity of which soon carry off the patient, but those old cases of
gradual vital waste, the mortality of most of which was formerly attributed to
"marasmus" and "inanition."

Of the patients received in the course of the year, 57 were removed from the
other two State hospitals, at Worcester and Taunton.

"There are now in the hospital one hundred and seventy-eight female patients,
and the part of the building allotted to them is filled, and in some parts rather
crowded. Yet the ample and well ventilated dormitories and corridors prevent
the usual bad effects of a crowd, and a remarkable degree of health is always
enjoyed. The disproportion between the number of males and of females exist-

Men. Women. Total.

Patients on the 30th of September, 1859
Admitted in course of the year .

Whole number

Discharged, including deaths
Remaining September 30, 1860 .
Of those discharged, there were cured
Died

98 135 233

73 94 167

171 229 400

34 51 85

137 178 315

8 19 27

496

Bibliographical Notices.

[Oct.

ing from the opening of the institution has constantly increased, and the excess
in the number of females now reaches forty-one."

"By the kindness of friends in the adjoining village, we have been furnished
with a great number of very pleasant musical entertainments ; and these, toge-
ther with a regular singing school through the winter season, and with exhibi-
tions of various kinds, tableaux and theatrical performances by the patients and
their attendants, have afforded abundant innocent amusement, and pleasantly
occupied many of the long winter evenings. Riding and walking, coasting and
skating, and various games, amuse and interest those capable of joiniug in them.
Once in three or four weeks a dancing party, in which both sexes are allowed
to join, affords a favorite recreation, more popular, perhaps, than any form of
amusement in use.

"The library has been somewhat increased, both by purchase of books and
by donations from benevolent individuals ; and, although much smaller than our
actual necessities demand, affords much instruction and amusement."

Dr. Prince discusses no medical question, illustrates no special medical sub-
ject in his report, but confines himself mostly to a narrative of the proceedings
of the year, and an exposition of the hospital's greatest defect — the liability to
temporary deprivation of its supply of water. It is to be hoped that this defect
will soon be remedied. The establishment, as a whole, is excellent; and we take
pleasure in here bearing testimony, after personal observation, to the beauty of
its situation, its general completeness, and the ability of its management.

Among the improvements of the year is a barn 104 feet in length and 54 in
width. P. E.

Art. XI. — A Practical Treatise on the Diseases of the HeaH and Great
Vessels, including the Principles of Physical Diagnosis. By Walter Hatle
Walshe, M. D., &c. a new American from the third and much enlarged
London edition. Philadelphia : Blanchard and Lea, 1862. 8vo. pp. 420.

It is interesting to compare the first edition of this treatise with the one just
published. The former is little more than the embryo, the latter the mature
and almost completed work. At first one small volume sufficed to contain all
that Dr. Walshe had to communicate respecting physical diagnosis in its appli-
cation to the lungs, heart, and great vessels. But that volume e^ddently pre-
sented the results of the author's personal observation and reasoning; it every-
where gave signs of a vigorous and original life, destined to a much more per-
fect expression. Even its sententious and sometimes uncouthly concise style,
revealed a latent power struggling towards complete development by the slow
but steadily progressive accretion of new materials and the assumption of a
more perfect scientific form.

The second edition, published in 1 8.54, and still embracing the whole of thoracic
pathology, assumed an imposing bulk, and gave evidence on every page that the
doctrines of the author were growing wider and more definite, and that however
» modest he might be in speculating where others did not hesitate to dogmatize,
he, nevertheless, felt himself competent to speak as one having authority. Dur-
ing the eight years that have since elapsed, the work of Dr. Walshe having
reached its maturity, by a fissiparous generation each half has established an
independent life, and two separate volumes, each of them nearly as large as the
preceding one, now contain the latest and fullest conclusions of the author re-
specting diseases of the lungs and of the heart.

Of the one before us it would be difficult to furnish such an account as would
convey an accurate idea, especially to the American reader who has not had
access to the second English edition, which was not republished here. Indeed,
we cannot but think that improvement in the diagnosis of cardiac diseases has
been notably retarded in this country by this omission. Those who have not
had access to this, or some equivalent source of information, will be surprised
to find how great a degree of certainty now attends diagnosis of the several forms
of organic and functional disease of the heart and great vessels, of the aflections

1862.]

MiLRoy, Health of the Rojal Navy.

of the two sides of the heart, and those of its several valves and orifices. They
will at the same time be struck with the number of circumstances which render
caution necessary in the formation of diagnostic opinions, and thus recognize
the extreme difficulty which, for all but thorough experts, environs many cases
in cardiac pathology, and which sometimes renders their analysis impossible
by trained physicians of the acutest senses and the maturest judgment.

It would be impossible for us to enumerate all the instances in which the
present edition excels the preceding one, for there is scarcely a chapter in it
which has not been enlarged by important additions, or materially modified in
its statements, while in several entirely new subjects are discussed. The fol-
lowing may be particularly referred to, as embod3^ing a large amount of new
matter: "The Weight and Measurements of the Heart;" "The Theory of the
First Sound ;" " Dynamic Intra-cardiac Murmurs ;" " The Impulse of the Heart ;"
" Influence of Stethoscopic Pressure upon Murmurs ;" "Auto-audible Murmurs ;"
" Perverted Innervation of the Heart ;" " Cardiac Motor Paralysis ;" " Syncope
" Angina Pectoris ;" " Anaemia and Congestion of the Heart ;" " Acute Pericar-
ditis "Alterations of Secretion in the Pericardium;" "Atrophy and Hyper-
trophy;" "Cardiac Flux;" " Fatty Heart ;" " Cancer of the Heart;" "Prog-
nosis, &c., of Diseases of the Yalves;" "Malpositions of the Heart;" "Intra-
cardiac Blood-concretions ;" " Cyanosis ;" " Inflammation, &c., of the Pulmonary
Artery ;" "Aneurism ;" " Cancer, &c., of the Pulmonary Artery and Yeins."

In elucidating these subjects the same precision of statement and compres-
sion of matter which distinguished the former editions are to be observed ;
indeed, the author appears to have studied with singular care, and to have illus-
trated with remarkable success, the difficult art of condensation. Whoever
seeks for easy reading will not find it here. On the contrary, the work demands
the closest attention thoroughly to comprehend it. And yet so far from being
chargeable with obscurity, its language is everywhere accurate and expressive,
and whoever takes pains to study it, will be convinced that it would have bees
difficult to compress more truth in fewer words. If it sometimes substitutes
the short and familiar phrases of clinical teaching, for the more polished locu-
tion of literary adepts, it is generally because the latter style is too poor in
appropriate words to depict the subject accurately.

With this passing notice, we commend the work to our readers as, perhaps,
the most valuable in the literature of cardiac pathology. Upon it, and its asso-
ciated treatise, On Diseases of the Lungs, we think that Dr. Walshe may fairly
rest his claim to stand in the first rank of his profession. A. S.

Aet. XII. — The Health of the Boyal Navy considered, in a Letter addressed
to the Rt. Hon. Sir John S. Packington, Bart. G. C. B., M. P. By Gavin
MiLKOY, M. D., F.R.C.P., Medical Inspector under the General Board of
Health from 1849 to 1854, Medical Commissioner to Jamaica in 1851, and
a member of the Sanitary Commission of The Army in the East, in 1855-56,
Svo. pp. 70. London, 1862.

It is very evident that the strength and efficiency of an armed force, whether
afloat or on shore, is to be measured, not by the number of names inscribed
upon the ship or regimental roll, however complete may be the material equip-
ments of the force, but rather by the actual number of hearty, vigorous men.
at any moment available for whatever duty they may be called upon to perform.
Every man whose name is upon the doctor's list is so much power withdrawn from
the effectiveness of the living machine. Not only is the force directly weakened
by the loss of such of its number as are excluded from duty by disease, but, in-
directly by the extra labour cast upon the well men to supply the loss of those who
are disabled by sickness, and of those also necessarily occupied in attendance
upon the latter. When disease prevails to any extent among a ship's crew, the
energies of the well are overtaxed, their hours for eating and sleep are inter-
No. LXXXYIIL— Oct. 1862. 32

498

Bibliographical Notices.

[Oct

fered with ; constant extra duty and fatigue create lassitude and discontent, and
the very state of system in which health is most liable to suffer from morbific
influences it had hitherto resisted. The means adapted to preserve, as far as is
possible, uninterrupted health among a ship's crew cannot, therefore, be over-
estimated. They are, in fact, to be ranked among the main objects to be aimed
at by all whose duty it is to look to the welfare of our navy, and to the mainte-
nance of its efficiency for the support and vindication of the rights, the integrity,
and the interests of our country.

The letter of Dr. Gavin Milroy, although confined to a rapid but most inter-
esting review of the health of the English navy, and of the causes by which this
is impaired, will be found to be replete with many important general facts and
conclusions, the hygienic teachings of which are equally applicable to the navy
of the United States, and have an especial interest at the present moment.

In considering the ordinary rate of sickness in the English navy, Dr. Milroy
confines himself chiefly to the years 1856, '57, and '58 ; the statistics collected
during this period furnishing the necessary facts and data to an extent and in a
form much more full, and satisfactory than those of any former period.

It is to be remembered that the year 1856 was very nearly one of peace. The
fleet was engaged during it in no hostile operations, either in the Black or Baltic
Seas. It was not until the very close of the year that hostilities commenced in
the Canton River. In 1857 the differences with China required a large increase
in the naval force on that station. Most of the ships were long anchored in the
Canton River, and their crews much exposed to the malarial influence of its
shores, besides their frequent sharp encounters with the enemy. This year, also,
the great Sepoy revolt took place, and a detachment from two of the frigates
joined the military force before Lucknow. In 1858, the East India and China
squadron was still further increased, and was actively engaged throughout the
whole year against both the Chinese and the Indian mutineers. Three battalions
of marines were for several months quartered in and around Canton, and had
most severe and harassing duties to perform in that unhealthy climate.

"In 1856, when the aggregate mean force of the navy was 51,730, the average
number of men daily on the sick list throughout the service was 3,132, or in the
proportion of 62 men in every 1,000 ; in other words, a seventeenth part of the
whole force was continually off duty from the effects of sickness or injury, either
on board ship or in hospitals on shore. In 1857, the daily sick rate was very
nearly the same, being only a fraction less. The aggregate force that year was
42,470. In 1858 the rate was higher, being in the proportion of 66 sick men in
every 1,000. The number at all times ineffective, out of a total force of 43,120,
averaged 2,859, or about one in eyerj fifteen men."

The sick rate, as might be expected, varies considerably in the different fleets
into which the navy is distributed, according to the stations where they are em-
ployed. The amount of sickness being, usually, lower in the Home, the Medi-
terranean, the Pacific, and the Australian stations than in the other fleets. But,
in fact, the rates vary so much in nearly all of them, from year to year, that no
very positive or uniform statement can be made on this head. Only two of the
fleets exhibit uniformly a high rate, of sickness — that on the west coast of Africa,
and, still more so, that on the East India and China station. The irregular force
also generally exhibits an unfavourable return.

The following table shows the mean strength of the different fleets, with the
average sick-rate of each for the three years 1856, '57, and 58 : — ■

Mean strength.

Average daily sick -rate.

East India and China fleet .
Irregular fleet . . . .
West coast of Africa fleet .
Cape of Good Hope fleet
North America and West Indies J
East coast of South America fleei
Pacific fleet . . . .
Mediterranean fleet

Home fleet

Australian fleet . . . .

fleet . 4,365

. 1,323
. 2,387
. 7,867
. 11,814

. 7,263

. 7,117

. 1,707

. 1,030

437

69
68
59
58
55
53
52
50
46

93 per 1,000 men.

1862.]

MiLROY, Health of tlie Royal Navy.

499

The number of days in the course of the year spent upon the sick list was, in
1856, throughout the navy, such as to give 22 days off duty to each man em-
ployed; in 1857 the proportion was a trifle more; and in 1858 it was rather
more than 24 days off duty to each man.

The rate of mortality in the navy varies much in different years, not only
on separate stations, but throughout the service generally — and this, too, inde-
pendently of the casualties of war and of all other accidents to which seamen
are exposed.

In 1856 the general death-rate from all causes was 15.5 in every 1,000 men ;
while the deaths from disease alone throughout the service were in the propor-
tion of 12.1 in every 1,000 of the force. In 1857 the proportion of deaths from
all causes was 22, and from sickness alone 14.7, per thousand. In 1858 the
general deaths from all causes was 25.8, and from sickness alone 20.2, per thou-
sand. The general average of deaths from disease for the three years was,
therefore, between 15 and 16 per thousand.

The mean death-rate for the three years was —

From disease

From all

alone.

causes.

On the Home station ....

. 7.8

10.3

" Mediterranean station

. 8.4

11.6

" North American and West India .

. 19.8

24.0

" Brazilian

. 21.0

25.2

" Pacific

. 6.9

8.7

" West African

. 14.3

20.5

" Cape of Grood Hope

. 10.2

16.3

" East India and China

. 37.7

47.6

" Australian

. 3.6

9.9

" Irregular

. ^ 8.3

12.4

In respect to the high death-rate of the East Indian fleet, we are reminded
by Dr. Milroy, that 1857 and 1858 were years of war, both in China and the East
Indies. During 1856 the death-rate was only 27 per 1,000 from disease, and 34
from all causes ; while in 1858 it was 51.9 from disease, and 62.5 from all causes.

Another cause of permanent loss to the service, from year to year, is the dis-
charge of all the men who are absolutely unfit for future duty in consequence
of grave organic disease, or of some incurable infirmity.

" In civil life," remarks Dr. Milroy, " the annual death-rate is our only avail-
able test in estimating the heathfulness or unhealthfulness of the community.
No means, as yet, exist for ascertaining, as in our army and navy, the statistics
of sickness among the population of our towns and rural districts. As to any
elimination of invalids among civilians, the only discharge of them is by death.
This circumstance alone presents a marked difference in the elements of any
comparison instituted between the ratio of mortality in naval and military life
on the one hand, and among working men of the same ages in civil life, on the
other ; greatly, of course, to the advantage of the former by so many incurable
sailors and soldiers having been discharged, and whose deaths on shore go to
swell the mortuary returns of the latter. What addition should be made to the
death-rate from disease in the navy to bring it more upon a par with the death-
rates in civil life, for the purpose of comparison, it is not easy to determine. It
cannot be less, I should think, than six or seven per thousand of the strength at
the least.

" In 1856 the number of men invalided was 998, or in the proportion of rather
more than 19 in every 1,000 of strength." In 1857 the number invalided was
1,460, or rather more than 34 per thousand ; and in 1858 the number was 1,763,
or nearly 50 per thousand. The mean rate for the three years together, in the
entire navy, was therefore between 31 and 32 in every 1,000 men. To show how
much this varied in different fleets, it may be stated that on the Home station
it was 23, while on the East India station in was 52 per thousand.
. " By putting together the number of deaths, and the number of men discharged
as invalids, in the course of the twelve months, the yearly total permanent loss
to the service is ascertained. In 1856 this amounted to 1,799 men, out of an

600

Bibliographical Notices.

[Oct.

aggregate strength of 51,730. In 1857 it amounted to 2,404, out of an aggregate
of 42,470 ; and in 1858, out of an aggregate of 43,128, it amounted to 2,878, or
a loss equal to the combined crews of three of the largest line-of-battle ships in
the navy.

" To put the facts in another way, the proportion of total permanent loss to
strength in 1856 was, throughout the navy, 34.8 per thousand men; in 1857 it
was 53.8 per thousand; and in 1858 it rose to 66.7, or a full fifteenth part of the
whole strength. If we take one or two fleets by themselves, we find that, on
the Home station, the mean rate for the three years of the total permanent loss
was 33 per thousand, or, deducting all the losses attributable to violence and
accident, that it was at least 28 or 29 per 1,000 of the strength. In the East
India fleet, the mean total loss for the trienniad was at the rate of 95.9 per
thousand, or little short of 10 per cent, of the force per annum.

" There is often observed a marked difference in respect to the healthiness
of different ships of the same squadron. While some are particularly sickly,
others, similarly employed, and exposed, apparently, to the same external or
atmospheric influences, are comparatively healthy. The greater sickliness of
some ships over others may be for one season or year only, or for a succession
of two or three years. Occasionally a ship has been so uniformly unhealthy-,
whenever it has been put in commission, as to acquire a thoroughly bad name
in the service.

" The cause or causes of this difference in the salubrity of diff'erent vessels in
the same fleet is not in every case very apparent. In sanitary investigations
we are often led astray by our attention, under the influence of some favourite
hypothesis, being confined to one set only of agencies, while the action of others
equally morbific in their influence are underrated, or entirely overlooked. This
is the case in respect both to dwellings on land and vessels at sea.

"A house may, to the outward eye, be a picture of neatness and beauty; it
may be as trim and clean as hands can make it ; it may have been well con-
structed, with drains and sewers, which are carefully looked after to prevent all
obstruction, its sitting rooms may be well aired and as fresh and sweet through-
out the day as can be desired, and yet in such a dwelling some of the inmates,
whose health previously had been good, are constantly ailing — with headache,
loss of appetite, and general malaise and debility, if not with bowel and febrile
complaints. And all this may be owing to some overlooked and unknown old
cesspit under or close to the basement, or to the foundation being damp and
unaired, or to a stagnant pond or manure heap close by ; or it may be that the
doors, windows, and heat registers of the bedrooms are so closely fitted, that
not a breath of air can pass into or out of the rooms at night ; or that too many
persons may sleep in one small chamber — which also may be on an ill-ventilated
basement floor, or over a stable or an outhouse, where dust and refuse matter
are allowed to accumulate. Or, with none of these evils, the water supply may
have acquired some taint or impregnation, which slowly but surely affects the
health."

The same is true in respect to a ship. She may be damp, deficient in ventila-
tion, or overcrowded, or she may be stationed in the neighbourbood of unhealthy
localities — the low, marshy shores of sluggish rivers, from whence, under the
influence of a hot moist atmosphere, an accumulation of decomposing organic
matter is continually 'exhaling morbific miasmata. Or, again, there may be
malarial exhalations from impurities in the hold — from putrid bilge matter,
slowly decomposing vegetable matter, or the decay of a portion of her own
timbers.

According to Dr. Milroy, the diseases which occasion by far the greatest
amount of mortality in the English navy are fevers, diseases of the bowels, and
affections of the lungs.

Fevers vary much in frequency and fatality in different years at all the naval
stations. The ships most exempt from their influence are those on the home
station. The annual number of deaths from fever among the crews does not
average more than eight or nine. Very many of the attacks result from intem-
perance and exposure to wet and cold, when the men get liberty to go on shore.
Occasionally, however, the fevers are of a decidedly typhoid or typhus character.

1862.]

Mil ROY, Health of the Royal Navy.

501

The estuary of the Medway is set down as the chief fever locality on the
Home station. The cases are generally of a periodic character ; occasionally
they are attended with severe gastric and bihous symptoms, when, usually, they
are of a more typhoid type.

Fevers are generally three or four times as frequent and fatal in the Mediter-
ranean as in the Home fleet. The majority of cases are of a mild continued or
remittent type ; about one-fifth are intermittent. The annual average frequency
of fever attacks on this station appears to be about 70 in every 1,000 men. The
annual death-rate from fever has averaged about two in the thousand.

It is on the West India station that the greatest amount of fatal fever cases
has of late years occurred in the English fleet. Fully one-half of all the deaths
from fever throughout the service, in the years 1856, '57, and '58, were caused
by yellow fever. Dr. Milroy remarks that this disease has been more fatal on
board the English ships of war during the last fifteen or twenty years than was
ever known previously, and all the vessels which have been smitten most severely
have been steamers.

" That the excessive heat on board, without adequate free ventilation, has had
much to do with the increased malignancy of the disease, is, Dr. M. thinks,
more than probable. It would seem, too, that the accumulation of dirt and
other offensive rubbish under the machinery, etc., has in several instances added
not a little to the impurity of the close hot air in the between decks. On some
occasions particular parts of a smitten ship appear to have been the especial
focus of the poisonous action." And this in nearly every instance has been
traced to some evident source of malaria existing in the infected quarter.

" The prompt abatement, and often the complete cessation of the disease when
the crew of an infected vessel have been moved out of her into clean, airy quar-
ters on shore or afloat, afford," Dr. M. remarks, " conclusive evidence how much
the ship herself is apt to be the chief cause of its malignancy and persistence."

An important inference deducible from this fact is, that, by the simple expe-
dient of securing a free circulation of. pure air at all times, but more especially
from sundown to sunrise, to every one without exception on board a sickly ship,
the virulence and extension of the disease would be greatly controlled. When-
ever, we are told, the sick have been treated in tents or under an awning on the
upper deck, instead of in the usual sick bay, and the between decks has been
kept fully ventilated, salutary effects have been always obtained.

The fleet on the east coast of South Amerirca sustained, also, serious losses
from yellow fever in 1856, '57, and '58, as well as in some former years. The
Brazilian station, formerly exempt from all malignant fevers, and considered
even more healthy than the Home station, has, within the last ten or twelve
years, become particularly destructive to the health of the seamen in consequence
of the prevalence there of the yellow fever which made its first appearance in
1849-50.

On the Pacific, Cape of Good Hope, and Australian stations fevers are repre-
sented as being comparatively rare and mild. In the West African squadron,
a great reduction of the mortality from fevers has taken place for many years
past. The annual death rate from fever has not exceeded during the three
years, 1856, '57, '58, five per thousand of the strength. This reduction is re-
ferred, in part, to the absence from the African coast of the malignant form of
yellow fever, and partly, also, to the salutary changes in the mode of conducting
the duties of the station which have been introduced upon the recommendation
of the medical department of the service.

The eruptive fevers are comparatively rare among seamen. The only one of
the exanthems which demands attention, in reference to the navy, is smallpox.
Of this disease, there occurred in the Black Sea fleet, during 1854 and 1855, 81
cases, of which five proved fatal, and in the Baltic fleet, 303, of which 18 were
fatal. In the majority of instances, the disease seems to have been caught be-
fore the ship sailed from England.

In 1856 the whole number of cases of smallpox throughout the entire service
was thirty-nine. They occurred chiefly in the Home and Mediterranean fleets.
Three of them were fatal. In 1857 the number of cases in the service was
twenty, ten on the Home, and six on the East India station ; neither fatal. In

502

Bibliographical Notices.

[Oct.

1858 the number of cases was 83; 47 on the Home, and 31 on the East India
station ; ten proved fatal.

Bowel complaints, chiefly alvine fluxes and cholera, cause the principal amount
of the mortality in the fleet, every year, in the Indian and Chinese waters. On
the other stations they are less prevalent and destructive. Everywhere, at times,
especially during the summer and autumn, more or less severe outbreaks occur
in particular ships — often on board those in harbour on the British coast, as
well as in the Mediterranean and elsewhere. The diarrhoea is sometimes de-
cidedly choleraic in character — occasionally sporadic cases of malignant cholera
are met with, usually between the beginning of July and the end of September.

Dysenteric attacks are more frequent and severe in the Mediterranean and
West India than the Home fleet, but are seldom productive of much mortality.
Of the entire number, 492, of deaths from dysentery and diarrhoea throughout
the service in the three years under review, 425 occurred in the East India and
China fleets. In the year 1858 alone, there were 252 deaths. On this station,
also, most of the deaths from cholera took place, namely, 138 out of 160, the
entire number. Of these, 110 occurred in 1858.

A good deal of the sickness on this station is ascribed to the recklessness and
wilful neglect on the part of the men of the most obvious precautions. The
officers, generally speaking, suffer much less than the men, and this in conse-
quence, mainly, of their greater attention to their food and clothing, and more
temperate habits.

The use of the impure water of the Chinese and Indian Rivers is set down
by some as having much to do with the prevalence of alvine flux in the fleet
upon this station ; and yet it is alleged that the crews of the ships who drank
only water distilled from their engines have suflered as much as those by whom
no such precaution was observed.

It has been observed that diarrhoea has sometimes attacked the crews of ves-
sels on entering the rivers of China, before they had any communication with
the land, or had partaken of any food or drink peculiar to the locality, the origin
of the disease in such cases has been referred to malaria ; but, at other times,
the ship's companies entirely escaped any degree of bowel complaint until after
they had begun to use the river water. And this difference in respect to the
period at which the disease occurred would be observed usually in the different
vessels of the same fleet, and at the same season of the year.

As Dr. Milroy remarks, the fact, that the tendency to diarrhoea and dysentery
is greatly increased by exposure to an impure atmosphere, is fully recognized by
medical men everywhere. These diseases are the most common pest of crowded
and ill-found emigrant and transport ships in all climates, and are more destruc-
tive than almost any other to armies, whether in the field or in unwholesome
quarters and cantonments.

Long-continued observation has shown that bowel affections are much less
frequent and severe among the Chinese than among Europeans, and more espe-
cially British sailors ; and this difference has been attributed mainly to the use
by the natives of a less stimulating diet, and to their abstinence from spirituous
drinks.

We are somewhat surprised to find, that the amount of sickness throughout
the English navy, from affections of the respiratory organs, including consump-
tion, exceeds that from any other class of diseases, and often equals that from
fevers and alvine fluxes conjoined. To take one year for example, in 1856, one-
sixth of the entire sickness throughout the service was from this cause. The
propcrtion varies on different stations ; but the influence of mere climate is far
less thcin might be supposed. Although not so high as in the Home station,
where sudden and considerable atmospheric vicissitudes most prevail, there is
still an immense amount in the milder and more equable regions of the Medi-
terranean, and even under the tropical skies of the Old and New World alike.

" The mere inclemencies of weather at sea, even when combined with exposure
and great fatigue, have much less to do with the frequency and severity of these
ailments than most people suppose ; but it must be acknowledged that the reck-
less habits of seamen when on shore, and their disregard of ordinary precau-
tions against wet and cold, contribute not a little to their production. With

1862.] MiLROY, Health of the Koyal Navy. 503

respect to chest and throat diseases, as with fevers, and diseases of the bowels,
we have to notice the curious fact that there is often a marked difference as to
their prevalence in different ships of the same scjuadron. lyino- at the same
locality, and engaged on the same or similar duties. Whether this difference is
owing mainly to the damper state of the between decks in some ships than in
others, according as the wet or dry mode of cleaning them is pursued, or whether
some crews have greater facilities for drying their wet clothes and getting warm
food or refreshment on going below after a cold and stormy watch, and before
turning into their hammocks, or whether from any other cause, it is not easy to
say."

The most startling fact developed by Dr. Milroy is in respect to the very great
frecpiency of pulmonary tuberculosis in the English navy. A seafaring life has
usually been considered as to a certain extent prophylactic of that condition of
the system with which the development of consumption is associated. Experi-
ence has shown that, in more than one instance, civilians with a decided tend-
ency to the disease, have, after a few voyages to sea. got rid entirely of such
tendency. How comes it then that the disease should be so common among the
seamen of the fleet, in every portion of the world to which it is sent ?

Fevers, cholera, dysentery, and indeed every other malady to which seamen
are liable, vary in their frequency and severity at different seasons, on different
stations, and in different years. But in all years, and nearly alike in all climates
we find consumption to prevail — causing, upon the whole, a greater amount of
permanent loss to the service than any other single malady.

"During the years 1856, '57. '58. .339 deaths were caused by consumption, and
111 by other diseases of the respiratory organs, chiefly pneumonia and bronchitis.
In the same period 533 seamen were discharged out of the service on account
of consumption — which in the great majority of cases would prove fatal within
six months of their discharge — and 171 on account of other confirmed pulmonic
diseases. The average of deaths from consumption alone averaged for the three
years 2.6 per 1000 of strength; and the corresponding ratio of the number of
men invalided on account of this disease was 3.9."

The Eoyal Commission to inquire into the sanitary state of the English army
refer the great prevalence of pulmonary consumption among the soldiers gene-
rally, and its inordinate frequency among the household troops, to the close foul
air of the crowded barrack-rooms at night. Dr. Milroy describes the atmosphere
of the lower between decks of a ship of war.- after the men have turned into
their hammocks, as equally stagnant and impure. And. he remarks : —

'• When it is remembered that the men have suddenly to turn out from this
close, damp, and fetid air at night to go on deck in all weathers, the exceeding
frequency of those ailments which always tend to accelerate the development of
tubercular disease is only what might be expected."

By far the greater number of deaths in the English navy from diseases of the
brain and nervous system — 172 in all — are referred to the effects, more or less,
of intemperance. T'hey are classed under the heads of apoplexy and delirium
tremens. The number hopelessly ruined in health and invalided, chiefly in con-
sequence of epilepsy and insanity, swells the loss to the navy from nervous dis-
eases to 501. This aggregate gives, however, but an inadequate idea of the
entire sacrifice of life and service arising from intemperance. Independently of
many attacks of disease attributable to intoxication and its consequences, very
many of the violent deaths from drowning, suicide, etc. are due to it, while nine-
tentiis at least of all the crimes and offences are committed by the seamen whilst
under the influence of liquor.

The amount of permanent loss to the navy by invaliding f rom disease alone
always largely exceeds that by death from this cause. In 1856. '57. and '58 it
was two-fifths greater: the total number invalided being 4221. and of this aggre-
gate 3808 were from disease alone ; the deaths during the same time from disease
being 2125. Disease of the lungs was the occasion of 692 cases; three-fourths
of these were consumptives. Disease of the bowels, chiefly dysentery, furnished
585 cases; and 162 cases were due to the sequela? of fevers.

Various maladies which add but little to the death list cause, annually, a large
amount of invaliding. During the three years, 1856, '57, '58, 448 cases were

504

Bibliographical Notices.

[Oct.

due to rheumatic affections, 286 to diseases of the heart, 263 to ulcers and
abscesses, . 244 to hernia, 243 to venereal diseases, and 235 to debility — compli-
cated generally with some internal organic mischief, often of the lungs. For
the purpose of comparing the losses by war, and accidents specially incident to
naval life, Dr. Milroy selects the Baltic and Black Sea fleets in 1854 and 1855,
and the East India and China squadron in 1857, '58, during the period of hostil-
ities with China and the Indian mutiny.

The total mortality during the Russian war, in the fleet, including the naval
brigade and marines serving with the army before Sebastopol, was from disease
1574; from accidental injuries, suicide, and drowning, 228 ; from.wounds received
in action, 227.

In the Baltic fleet the loss from wounds received in action was only 15 in 1854,
and in 1855 only 11. In the Black Sea fleet, in 1854 the total loss from the
casualties of war, afloat and on shore, was 94. In 1855 there were 104 deaths
from wounds received in action. Among the East India and China squadron,
in 1857, there were 87 violent deaths out of a mortahty of 327. Of these 87,
38 were from wounds received in action, 29 deaths resulted from drowning, 13
from accidents, 2 from suicide, and 3 from causes unknown.

In 1858, out of a total mortality of 706, of which 120 were deaths from vio-
lence, 35 were from wounds in action (in China 27, in India 8) ; 49 deaths were
from drowning, 17 from accidents on board ship, 3 by suicide, 1 by lightning,
and 15 from causes not positively ascertained — either from violence or injury
while ashore on leave, or in action with the enemy.

Thus, in the three years — 1856, '57, '58 — 82 sailors and marines lost their lives
in action, and 89 by drowning.

During these three years the number of men invalided in consequence of acci-
dents and wounds amounted to 483, out of a total of 4221 from all causes, or
nearly one-tenth part of the whole.

The inference deducible from the foregoing facts is, that a considerable portion
of the losses of men in the service of. the navy are due to causes which are not
inevitable to life on shipboard, or to the services in which the vessels of the
navy are liable to be engaged during a state of peace or war. That most of
these causes are apparent, and with due precautions may be prevented or re-
moved. All that is necessary is that the attention of all the officers of the ser-
vice, executive as well as medical, and of the general educated public also, be
continually directed to wateh the influence of every circumstance affecting the
preservation of health and the occurrence of sickness in ships, and that all
encouragement be given by the administrative authorities for the promulgation
of sound opinions, and the tentative adoption of reasonable suggestions.

D. F. C.

Art. XIII. — Hcemorrhoids and Prolapsus of the Rectum : Their Pathology and
Treatment ; with special reference to the Application of Nitric Acid. With
a chapter on the Painful Ulcer of the Rectum. By Henry Smith, F.R.C.S,,
Assistant Surgeon to King's College Hospital. Third Edition. London,
1862. 12mo. pp. 141.

In the July number of this Journal, for 1860, we noticed the preceding edition
of this work. The manner in which Mr. Smith employed nitric acid in the treat-
ment of piles and prolapsus recti, which is the special point of interest in tfiie
book, is there fully described. In the preface to this present edition, the author
states that in it he has described and illustrated certain modes of treating
haemorrhoids and prolapsus which were not alluded to before, but which his
more mature experience has justified him in recommending, and that he has
added, moreover, a short, but entire chapter, on the painful ulcer of the rectum,
which is so often associated with, and mistaken for haemorrhoidal disease.

After having enjoyed more extensive opportunities for treating haemorrhoids,
Mr. Smith has materially modified the views he formerly expressed in regard to

1862.]

Wilson, Diseases impeding Reproduction.

505

the use of nitric acid. As stated in the bibliographical notice above referred
to, he was formerly of opinion that certain forms of hasmorrhoids definitely
marked and easily recognized were speedily, painlessly, and permanently cured,
by its application. He feels now bound to state that the objection brought
against this agent, that it is an uncertain one. is to some extent valid, and that
in a few cases where he has employed it himself with the greatest care, scarcely
more than a trifling effect was produced. With respect to the permanency of
the cure, in several instances, both of hsemorrhoids and prolapsus, where the
agent has been employed, he has been able to ascertain that the result has been
permanent in some, while in others there has been some slight and temporary
return of symptoms readily removed by a resort to the remedy. With regard
to the pain, Mr. Smith states that he ^as met with a case now and then, since
the publication of the second edition of this book, in which the patient suffered
somewhat severely, but when this has been so, either the mucous membrane to
which the acid was applied was close to the verge of the anus, or a portion of
the acid had, through carelessness, come into contact with the integument.

When there is a doubt about the case as regards the applicability of the nitric
acid, and the patient is not a fit subject for the ligature, or will not submit to
this operation, Mr. Smith, in the present edition, recommends as an excellent
mode of treatment, one he states to have been originally suggested by the late
Mr. Cusack, and highly spoken of by Mr. Lee. This consists in compressing the
hasmorrhoidal tumour by means of a blunt pair of scissors or clamp, and snip-
ping away the free portion with sharp scissors ; the cut surface of the tumour is
then carefully wiped with a piece of sponge or lint, and then the nitric acid is
freely applied to every portion. Of course, no bleeding can take place if the base
of the hasmorrhoid be well secured by the clamp ; and so soon as the raw surface
is thoroughly imbued with the acid, the clamp is removed, and although the
pressure is taken off, bleeding is arrested by the action of the caustic. This
mode of treatment Mr. Smith believes to be particularly well adapted to pro-
lapsus of the rectum, and in the portion, of the book devoted to this affection
details of cases are given where hsemorrhoidal tumours and prolapsus of the
rectum were thus successfully treated.

In the newly added chapter on the painful ulcer of the rectum is contained
nothing that is worthy of notice as new, and many things are omitted that
should have been inserted. The chapter is by no means one to be styled
"entire," in the usual acceptation of the word; on the contrary, it is in every
way incomplete and defective.

The several editions of Mr. Smith's work display on the part of the author
more of enthusiasm and of frankness, than of discretion. He has too hastily
published the immediate results of a particular mode of treatment, with which
he had become delighted, and after further experience he has candidly acknow-
ledged its failures. W. F. A.

Akt. XIY. — On the Diseases impeding Reproduction in the 31ale and Female:
being the Pathology and Treatment of Spermatorrhoea., Impotency, and Ste-
rility. By Maiiris Wilson, M. D., M. R. 0. S. E. London: Tallant & Co.
[The author reserves the right of translation.] 8vo. pp. 225.

Tn the number of this Journal for January, 1859, we noticed an edition of the
well-known treatise of Lallemand on Spermatorrhoea, to which was added a
treatise by Dr. Marris Wilson, entitled On Diseases of the Vesiculce Seminales
and their Associated Organs ; luith special reference to the Morbid Secretions
of the Prostatic and Urethral Mucous Membrane.

The present volume consists of the latter treatise, with extensive additions.
Impotency and sterility are treated of, and anatomical descriptions and explana-
tions of the male and female organs of generation are introduced. This the
author has endeavoured to do "as concisely as possible, and with an avoidance,

506

Bibliographical ^foTicEs.

[Oct.

as far as it could be done, of any teclinical expressions." "It must be acknow-
ledged," he adds, "that one of my purposes has been to lay the conditions plainly
before those interested, and give them at least the chance of testing the many
wild and groundless assertions made respecting these diseases by unqualified
persons."

The citations we have made from the preface are sufficient to determine the
character of this work of Dr. Wilson. Our examination of it has inspired us
with intense disgust, and we must say that a proper regard for public morals
would lead to its publication being suppressed. W. F. A.

f—

Aet. XY. — A Medical Handhook, comprehending such Information on
Medical and Sanitary Suhjects as is desirable in Educated Persons: with
Hints to Clergymen and Visitors of the Poor. By Frederick William
Headland, M. I)., B. A., F. L. S.. Fellow of the Royal College of Physicians,
etc. 12mo. pp. 348. London, 1;!61.

The work before us is, in strict parlance, a compendium of so much of the
science and art of medicine as relates to the means of preserving health and of
curing disease, drawn up expressly for popular use.

To teach every man to be his own doctor by simply placing in his hands a
popular treatise or manual of the practice of medicine is impossible; .he attempt
has always been not only a failure, but the cause of positive mischief, and that
often of a very serious character.

To decide upon the true character of disease, and detect the modifications
produced in it by causes connected with the sex, age, constitution, temperament,
pursuits, and condition in life of the individual in whom it is met with, or with
the climate, location, and season at which it occurs, and with the prevailing
epidemic tendencies ; to apply with judgment and success the remedial measures
best adapted for the control of whatever disease is ascertained to be present,
demands an amount of professional knowledge and skill which can be mastered
only by an entire devotion to the task of the time and talents of whoever shall
pretend to assume in any case the office of physician. The practice of medicine
must necessarily, therefore, be committed to those who have been expressly
educated for that single object, and who are prepared to make it their sole and
entire pursuit.

While we insist that it is impossible to write a book which shall enable the
unprofessional reader to diagnosticate and treat diseases, still we are convinced
that a work might be prepared for popular use, which would be eminently ser-
viceable in pointing out the causes of disease, and teaching how these deleteri-
ous influences may be guarded against.

The handbook of Dr. Headland does not, we fear, fulfil the requirements for
such a work. The first part — the hygienic portion — though sound in its doc-
trines, is very superficial; and in the second portion the author has attempted
what it is impossible to accomplish, and has of course failed. D. F. C.

1862.]

50t

QUARTERLY SUMMARY

OF THE

IMPEOYEMENTS AND DISCOVERIES

IX THE

MEDICAL SCIENCES.

ANATOMY AXD PHYSIOLOGY.

1. Ahsorhing Poicer of the Human SJcin. — Dr. Murray Thompsox, Lecturer .
on Chemistry. Edinburgh School of Medicine, Tolsites [Ednib. 3Ied. Journal,
May. 1862) some experiments which he tried on his own person to ascertain the
truth of the statements made as to the curatiye power of mineral water baths,
depending on the absorption by the skin of certain salts and other substances
which they hold in solution ; and further, to ascertain whether certain substances
applied in the form of ointments, &c. pass through the skin and reacli the blood
before they produce any beneficial effect. .

His conclusions are, "that not only has absorption by the skin been greatly
exaggerated, but that, in the case of substances in aqueous solution, it seems to
be the exception, not the rule, for absorption to take place; and, in the case of
ointments, etc., some substances so applied appear to be absorbed and others
not. For instance, I haye nowhere read any contradiction to the well-known
statement that mercury is absorbed in inunction. My own trials, though too
few to lead me to an opposite conclusion with regard to iodine and iodide of
potassium, certainly tend in that direction.

"As to the tincture of iodine, my many experiments with it compel me to say
that it is seldom or neyer absorbed. As far, therefore, as the specific action of
iodine is concerned, this remedy might be abandoned. At the same time. I am
quite aware that painting with tincture of iodine is held to operate beneficially
as a counter-irritant. I do not for a moment question this view of its use. My
experiments lead me only to the conclusion that the iodine in it is not absorbed."

2. Researches on the Influence of Culinary Salt and Coffee on the Metamor-
phosis of Tissue. — Culinary salt, according to the researches of C. Yoit, is a
powerful stimulator of the metamorphosis of tissue ; it increases, by means of
its physical properties, the capillary circulation of fluids in the organism ; it
increases the oxidation of albumen, and through this the quantity of urea ex-
creted. Culinary salt is also a true diuretic. In order to excrete the salt from
the body, water is required ; this water passes always through the kidneys (the
only channel for the excretion of culinary salt in the dog), and is, if the supply
of water from without is limited, abstracted from the tissues.

Yoit's experiments with coffee on a dog led to the inference that coffee does
not, as is usually assumed, diminish the metamorphosis of nitrogenous tissue,
and the excretion of urea, but, on the contrary, rather increases these processes.
On the whole, the dog appeared to be more lively after the use of coffee. The
author made also experiments with coffein on frogs, and found it to cause, at
first, increased irritability of the nervous system, a tendency to reflex-movements
and to tetanic convulsions ; later, however, phenomena of paralysis. The pupil

508

Progress of the Medical Sciences. [Oct.

becomes dilated ; the capillary vessels are filled with blood ; the heart's contrac-
tions are at first increased, later reduced in frequency, they are arrested during
the tetanic paroxysms. The author attributes the principal effects of coffee to
its action on the nervous system, not to its influence on the tissue-change. The
nervous system being rendered more susceptible, the same exciting cause pro-
duces a greater effect. Coffee thus refreshes, Yoit thinks, the fatigued body,
renders the lassitude less perceptible, and in this manner enables us to endure
prolonged exertion. The experiments on the influence of bodily exercise (tread-
wheel) on the tissue-change in the well-known dog lead to the unexpected result,
that the excretion of urea was not at all, or only very slightly, increased by
bodily labour. Yoit infers, therefore, that muscular action does not cause in-
creased decomposition of albuminous substances, while it is accompanied with a
greater consumption of fat. As the decomposition of albumen is not the source
of the production of force, connected with muscular contraction, Yoit is inclined
to look for it in the development of electricity. — Brit, and For. Med. and Surg.
Jowrn., July, 1862.

3. Calorific and Vascular Nerves of the Sympathetic. — M. Claude Beenard,
in a paper, the first of a series to be presented to the Academy of Sciences,
endeavours to demonstrate that the vascular and calorific nerves are special
nerves to be topographically and physiologically distinguished from the ordinary
motor nerves. Having opened the spinal canal in dogs, he divided as they left
the cord all the origins of the sacro-lumbar plexus (sometimes on one side and
sometimes on the other) which supplies sensation and motion to the hinder
extremity. The limb became completely paralyzed, but no calorification or
vascularization was observed, the temperature on this side often, indeed, dimin-
ishing. When only the posterior and anterior roots were divided, corresponding
abolition of sensation or of motion occurred ; but in neither case was there any
vascularization or change of temperature in the limb. In a dog in which com-
plete paralysis of the left hind leg was produced by division of the origins of
the sacro-lumbar plexus, the sciatic nerve was afterwards divided. Its origin
having beeu already divided, the subsequent section was not felt, and added
nothing to the paralysis of motion and sensation that already existed ; but
vascular and calorific phenomena immediately followed, the temperature of the
limb steadily rising until it was from 6° to 8° 0. higher than that of the opposite
one, and so continued until the death of the animal next day.

The experiment was repeated a great many times with exactly the same result.
It is evident, therefore, that nerves influencing these functions must have become
adjoined to the motor and sensitive nerves in the short interval between their
issue from the canal and the point where the sciatic was divided. It is only
the sympathetic, placed on the sides of the spinal column, which could thus
become joined to these nerves ; and M. Bernard in another experiment, destroyed
the ganglion of the sympathetic and its filaments, which lay upon the side of
the fifth and sixth lumbar vertebrge, leaving the nerves of the sacro-lumbar
plexus entirely intact. An excess of temperature in the limb was immediately
observed, and during the three days the animal lived, the paw of the side operated
upon was from 5° to 8^^ hotter than the other — no paralysis whatever being pre-
sent. The conclusion to be drawn is that there are three distinct descriptions
of nervous influence — 1. The sensitive, due to the posterior roots of the sacro-
lumbar plexus; 2. The motor or muscular, belonging to the anterior roots ; and
3. The vascular and caloriflc, due to the sympathetic. — 3Ied. Times and Gaz.,
Aug. 23, 1862, from Gaz. des Hop., No. 94.

MATERIA MEDICA AND PHARMACY.

4. Is Alcohol Food? — Dr. Thomas Tnman, of Liverpool, read an interesting
paper on this subject before the British Medical Association at its late meeting
in London.

The author first devoted a few words to definition, stating that by "alcohol"

1862.]

Materia Medica and Pharmacy.

509

he intended to comprise those liquors in common use which owed their effects
to alcohol; and by "food," anything which supplied material by which the body
was nourished. He then adverted to the fact that a saccharine material was
found in the blood of all mammals when it entered the lungs, and to the strong
probability that a fermentative process took place in those organs, with the
extrication of carbonic acid, the actual source of which in the blood had not yet
been absolutely ascertained. The close atomic composition of starch and sugar
and alcohol plus carbonic acid was pointed out ; also the fact that the starches,
&c., and alcohol were often tolerated by delicate stomachs when other ingredients
were not tolerated.

The author then shortly summarized the effects of ordinary food, whether
animal or vegetable, when taken with water for a beverage and in proper quan-
tity, and compared these with the results following a temperate draught of ale
or porter ; showing that there was no real distinction between the one and the
other, except that the liquid sooner entered the circulation and sooner left it.
It was no argument against the use of beef that a man who had dined on it one
day wanted a dinner the day after ; nor against beer, that a person who had
taken one glass was ready for another in a few hours. The prejudicial effects
of excessive eating were adverted to, and after mentioning a few instances where
guzzling had proved fatal, others were alluded to in which a prolonged lethargy
or an apoplectic condition had been induced. The use of beef tea sometimes
produced convulsions in infants, but this result did not vitiate the dietetic value
of meat. The physical condition of excessive eaters was then spoken of, and it
was shown that some were thin, others stout ; and that as regarded the moral
condition of those who, from choice, religious belief, or necessity, abstained from
the use of alcoholic beverages, they were to the full as bad as those who indulged
in drink. Cannibals were teetotallers, and neither Nana nor Tippoo was a drunk-
ard. On inquiring into the habits of total abstainers and those who drank ale,
wine, &c., the author had ascertained that the former habitually ate much more
than the latter ; and one of three deductions was necessary : either the former
ate too much, the latter too little, or the drink of the one was equivalent to a
portion of the food of the other. To ascertain which of these alternatives was
nearest the truth Dr. Inman had experimented in his own person, and had made
numerous observations through the assistance of friends. The conclusion he
came to was that which had been previously insisted on by Mr. Lewes and
others — namely, that alcohol replaced a certain amount of food ; and "as things
which are equal to the same are equal to one another," he inferred that if a glass
of ale was equal to a slice of mutton in its satisfying effect, and that mutton was
food, it must follow that ale is food. To say that persons could not live on ale,
was of no value as an argument ; for no one could live on biscuit alone, though
bread was called the staff of life. To ascertain how far it was possible for any
one to live on alcohol alone, he had for many years been seeking information
respecting drunkards, and he mentioned two — one on the authority of the indi-
vidual herself (a surgeon's widow), and the other on the authority of the medical
attendant, where patients had subsisted for a prolonged period on brandy and
water alone. He mentioned others on the authority of other medical friends,
and two which he had himself been conversant with. He combated the idea of
the probability of imposture, inasmuch as in all these cases solid food was
loathed excessively, and was generally rejected by the stomach. He then men-
tioned some cases of children that he had attended, in whom the appetite had
failed entirely, where food which was administered by force had been vomited,
yet in these alcohol in one form or other gave the support which other food did
not, and gradually restored the appetite to its normal state. He noticed, too,
that infants at the breast, when ill, would digest brandy and water when they
would reject all else. The advantageous influence of this fluid was apparent
even if it were administered in enemata.

A definite course of induction, irrespective of chemical theory, having ended
in the conclusion that alcohoHc drinks were strictly alimentary, he shortly refer-
red to the statements which were relied upon to demonstrate the contrary. If
alcohol, he said, passed out of the system unchanged, so did water ; yet water
was absolutely necessary to life. But there was no proof that all the alcohol

510

Progress op the Medical Sciences. [Oct.

imbibed in a long symposium ever left the body. He inferred that if it did pass
out of the lungs in vapour as largely as was assumed, a party of spirit drinkers
would make the atmosphere of a closed room explosive ; and he recalled the state-
ment of Pereira, that some northern race had found that two or three people in
succession might keep up intoxication with "lolium temulentem" by drinking the
urine of the first eater ; yet none had discovered that the urinal of a drunkard
contained anything equal to gin. But certain foods, as oatmeal, bran, potatoes,
oats, &c., were not wholly retained in the system, yet they were alimentary.

Dr. Inman then combated the idea that alcohol was a mere stimulant, by con-
trasting it with turpentine, cantharides, ginger, cayenne, iodide of potassium,
and other drugs, which were stimulants to every part of the body to which they
were applied. He argued that alcohol could not simply be a conservator of
tissue; for a glass of ale after a long walk would induce plentiful perspiration,
and a glass of whisky or gin and water acted with most people as a powerful
diuretic. Nor could we conclude that it assisted in disintegrating the tissues ;
for if it did, the use of ale, wine, or spirit must then be antagonistic or antidotal
to food, and the winebibber must necessarily require more food than the teeto-
taller, whose tissues were not disintegrated by artificial means.

He then summed up his conclusions thus : —

1. Nature has provided in the salivary glands, the liver, and the lungs of
every mammal an apparatus for converting all food, especially farinaceous, into
alcohol ; and we have no evidence that such conversion does not take place.

2. One form of alcohol or another is available for the support of life, and for
restoration to health when no ordinary food can be or is digested.

3. Alcohol, after being taken, is incorporated with the blood, passes into the
various tissues, and ultimately disappears, a small portion only passing away in
the breath. We can say no more of bread, potatoes, or oatmeal porridge, a
small portion of each of which passes out of the body with the feces.

4. Alcohol, in the form of ale, porter, wine, &c., relieves hunger and quenches
thirst simultaneously, and with a completeness that is not equalled by water,
infusion of gentian, cayenne pepper, or by turpentine — i. e., it does not act as
water simply, or as a stimulant alone.

5. Wine, beer, &c., satisfy the appetite when taken alone, and act for the
time like any solid food would do.

6. When alcohol is mingled with other food, a less amount of the latter suffices
for the wants of the system than if water had been used as the drink.

7. The various forms in which alcohol is taken have as marked and specific
effects as have animal and vegetable articles of diet.

8. Individuals have subsisted wholly upon one or other of the various forms
of alcohol in common use for periods of great length ; and as it is illogical to
conclude that they must have lived on air, without food, or on flies like chame-
leons, the conclusion is irresistible.

What that conclusion is, it might be left for every thinking man to decide. —
Lancet, August 16, 1862.

5. Rennet Wine. — Dr. Geo. Ellis states [DuUin Med. Press, July 16, 1862)
that about two years since, having failed to obtain benefit from the preparation
called pepsin, he had recourse to the direct preparation of a solution of gastric
juice from the calf's stomach, and with the most satisfactory results. His mode
of preparing is as follows : "Take the stomach, or rennet bag as it is called, of
a calf fresh from the butcher ; cut ofi" about three inches of the upper or cardiac
extremity, which portion, as it contains fewer glandular follicles, may be thrown
away ; slit up the stomach longitudinally ; wipe it gently with a dry napkin,
taking care to remove as little of the clean mucus as possible ; then cut it into
small pieces (the smaller the better), and put all into a common wine bottle ; fill
up the bottle with good sherry, and let it remain corked for three weeks. At
the end of this time it is fit for use.

" Dose. — One teaspoonful in a wineglassful of water immediately after meals.

" Test of quality. — One teaspoonful will solidify, to the consistency of blanc-
mange, in from one to two minutes, a cup of milk (about eight ounces) at the
temperature of 100^ Fahr.

1862.]

Materia Medica and Pharmacy.

511

"In this action on the casein of the milk, it may be said that the wine itself
might have some effect. This, however, cannot be the case, as wine will not
solidify milk, and it will only curdle it at a much higher temperature, and in
larger proportion."

A single dose of this preparation, which Dr. E. calls rennet wine, given daily
after dinner, will, he says, " be found quite sufficient to act speedily and effect-
ively, without other treatment, in the common run of cases of functional dis-
order of the stomach. It is not, perhaps, easy to explain the operation of this
small quantity when we consider the large supply of the gastric secretion re-
quired for the thorough digestion of an ordinary meal. The action is probably
due to those indirect chemical changes called catalytic transformations, which
some organic substances, by their mere presence and contact, induce in each
other, and in other proximate principles. Thus the conversion of a small por-
tion of food in the stomach into healthy albuminose by this small quantity of
sound gastric juice may induce the same healthy action throughout the stomach
contents during the entire process of stomach digestion. It is at least equally
difficult to explain the action and rapid extension of ferments generally in their
appropriate solutions. I have often been forcibly struck by the magical effect
of this small dose in removing offensive odour from the breath of young persons
— a distressing symptom sometimes aggravated rather than relieved by purga-
tive medicine ; and I may also mention that in one of these cases cod-liver oil
was easily tolerated afterwards though never before."

6. Preparatwn of Oxygenated Water, and its Therapeutical Use. — Dr.
OzANAM gives the name of oxygenated water to water which is distilled and
afterwards charged with oxygen under the influence of high pressure. The
experiments he has made have led him to establish three modes of operation by
this new medicine. 1. It improves the condition of the blood in cases where
that fluid is impaired or deficient, as in dyspnoea, asthma, slow asphyxia, cya-
nosis, diseases of the heart, haemorrhoids, and hsemorrhoidal visceral congestion.
2. It possesses an oxidizing or metamorphic action in cases where the organic
products are arrested in their development, as happens in glycosuria, gout, the
uric and oxalic gravel, and perhaps in scrofula. 3. It exerts an exciting and
regulating action on the brain and the thyroid gland, and hence its use in goitre
and cretinism. If, in fact, snow-water taken as drink gradually produces these
morbid conditions, it is because it is entirely deprived of vital air. On the other
hand, oxygenatecT water, as well as the inhalation of gaseous oxygen, produces
no results in hemicrania, and unfavourable ones in cases of inflammatory disease.
Thus, in croup, the oxygen temporarily tranquillizes the dyspnoea, but it increases
the fever. In the treatment of ulcerated cancer the oxygenated water revives
pretty well the powers of the patient, and the wounds assume a more vivid and
rosy colour, but they do not heal ; and if the surfaces are bathed with rags
steeped in oxygenated water, even when very slightly charged, the ulcer is soon
observed to become gangrenous on the surface. Oxygenated water is perfectly
limpid and pure, and the gas is disengaged in the form of very fine bubbles.
Having little taste, it resembles in this respect water which is deprived of air ;
and, like the latter, it is a little heavy for the stomach. — B. and F. Med.-Cliir.
Rev., July, 1862, from Compte Rendu de VAcad. des Sc., November, 186 L.

7. Medical Properties of the Wild Thyme {Thymus Serpillum) and its Use
in Spasmodic Cough. — M. J oset states, that by the simple administration of an
infusion of wild thyme, slightly sweetened and mixed with gum, he has observed
the improvement and even the cure, as if by enchantment, of cases of hooping-
cough, taken indifferently at all the periods of the disease. The same was the
case in stridulous sore throat, and in convulsive and catarrhal coughs. In the
worst cases of hooping-cough the pathognomonic paroxysms, although they did
not entirely disappear at the end of a few days, became so much modified in their
character, that the disease resolved itself into a case of simple bronchitis, which
was easily treated. These remarkable cures, so rapidly effected, and obtained
only by the administration of wild thyme, have led M. Joset to look upon this
plant as a sovereign remedy, and in some degree a specific one, in the affections

512

Progress of the Medical Sciences.

[Oct.

of the air-passages. The employment of this plant is not a novelty, for it was
formerly recommended very extensively in the treatment of obstinate coughs,
and it enters into the formation of some popular powders and syrups. M. Joset
advises it to be given in the form of a concentrated infusion, slightly sweetened,
to be taken in any quantity which the patient can drink, and until the desired
effect is produced. The favourable result has generally ensued at the end of a
very few days. — B. and F. Med.-Chirurg. Review, July, 1862, from Revue de
TliSrap., February, 1862.

8. Chemistry and Properties of the Cytisus Laburnum. — Dr. T. S. Gray
publishes [Edinb. Med. Journ., May, 1862) an elaborate investigation on this
subject. The following are his conclusions: —

" 1. That the crude drug has no irritant properties, and that the sickness and
vomiting which it produces when administered in large doses are due to some
action on the nervous system,

" 2. That these disagreeable symptoms may be, to a certain extent, avoided
by administering it in small doses.

" 3. That it is not, as is generally supposed, a purgative when administered in
small doses.

"4. That in small doses it has useful therapeutic properties.

"5. That the activity of the drug is owing to the presence of three vegetable
principles, and not of one, as stated by MM. Chevallier and Lassaigne.

"6. That the principles, when carefully separated, have valuable narcotic and
stomachic properties.

"7. That they have not the tendency of the crude drug to produce sickness
and vomiting, unless when given in very large doses.

•'8. That these principles are yielded in such quantity by the laburnum tree
that they might with advantage be introduced into the pharmacopoeia.

" 9. That the principles are yielded by all parts of the tree, but in largest
quantity by the bark and seeds.

" 10. That the administration of charcoal will be found useful in the treatment
of poisoning by laburnum."

9. Iodide and Oxy iodide of Antimony and their TJierapeutic Action. — Dr.
VAN DEN OoRPUT has employed in his practice for more than a year the different
compounds of iodine with antimony, and the oxyiodide in particular has yielded
such remarkable results that he considers it to be one of the most active of the
antimonial preparations. The iodide of antimony is obtained by carefully heat-
ing in a glass retort one equivalent of powdered metallic antimony with three of
iodine. The mixture soon fuses in the form of a thick liquid of a deep brownish-
red colour, which is the iodide of antimony; and on cooling it solidifies into a
mass which has a metallic fracture, and furnishes a powder of a brick-red colour.
If great heat is employed, the iodide is volatilized without decomposition, and is
condensed in the form of shining translucent scales. The reaction takes place
with the disengagement of heat, and may lead to an explosion if too large a
quantity is operated upon at one time, and therefore it is better to add the
metallic antimony gradually to the iodine. The iodide of antimony, when in
contact with water, is decomposed in the same manner as the chloride, into
soluble hydriodic acid and a pulverulent yellow precipitate formed of hydrate
of oxide and iodide of antimony, analogous to the powder of Algaroth. Alcohol
also decomposes it by removing iodine. The oxyiodide of antimony is the only
chemical form in which the combination of iodine and antimony can be conve-
niently used for internal administration, since by the contact with the liquids of
the digestive canal the iodide of antimony is decomposed, as it is in water, into
insoluble oxyiodide of antimony and hydriodic acid. The oxyiodide of antimony
may consequently be obtained by rubbing up iodide of antimony with water, and
thus decomposing it into hydriodic acid and oxyiodide of antimony of a bright
yellow colour; but it is better to prepare this compound by adding an acid solu-
tion of chloride of antimony to a solution of iodide of potassium. A precipitate
is immediately formed of a beautiful lemon-yellow colour, which after a few
minutes changes to an orange yellow. When the decomposition is complete,

1862.] Materia Medica and Pliarmacv,. 513

the precipitate is collected on a filter, washed, and dried. It is decomposed by
most of the acids ; hydrochloric acid dissolves it. setting the iodine free ; and
caustic alkalies also change it by combining with the iodine. When exposed
to heat, it is resolved into antimonious acid and iodide of antimony, which is
volatilized.

The researches of Dr. Yan den Corput have convinced him that the iodide of
antimony is chiefly adapted for external application as a revulsive. The irri-
tating properties of this salt resemble those of tartarized antimony ; while the
oxyiodide, corresponding in its composition to Kermes' mineral, produces inter-
nally an action analogous to that of the last-named preparation, although its
special effects are much more powerful. The oxyiodide is, in fact, a drug of
great efficacy, being at the same time an expectorant and a powerful alterative.
When suspended in a mucilaginous vehicle, in the dose of from 5 to 25 centi-
grammes (a centigramme is .1543 of a grain), it frequently excites at first nausea
and sometimes vomiting, at other times it causes frequent and copious stools.
The effects may be easily moderated by the addition of opiates or some other
narcotic agent which is capable of deadening the susceptibility of the stomach.
Tolerance appears to be established more readily, as in the case of tartarized
antimony, by doses raised from 20 to 50 or even 70 centigrammes in twenty-four
hours. In general, when taken in such doses, the drug excites at first a great
diaphoresis, soon followed by diminution and considerable depression of the
pulse. The number of inspirations is diminished in frequency, and this effect is
accompanied by extreme muscular weakness. The oxyiodide of antimony is
particularly serviceable in inflammation of the parenchyma of the lungs, and
especially in the second stage of pneumonia; also in the treatment of subacute
bronchitis and of oedema of the lungs. Its alterative and diaphoretic properties
are also manifest in the treatment of acute rheumatic affections, as well as in
certain inflammatory diseases of the heart. As to the iodide of antimony, its
employment must be limited to the outside of the body. When applied to the
skin, in the form of plaster or ointment, it produces an energetic revulsion, by
causing on the surface a pustular eruption similar to that produced by tartarized
antimony. But it has this advantage over the latter, that, independently of its
local derivative action, it operates besides on the organism in a general manner
by giving up a part of its iodine, which is then either directly absorbed, or by
being vaporized by the heat of the body, surrounds the patient with an iodized
atmosphere. — B. and F. Med. Chirurg. Rev., July, 1862.

10. Professor Polli on Sulpliites. — A new series of salts, the sulphites, bisul-
phites, and hyposulphites of potash, soda, lime, and magnesia, which have hith-
erto been known only by the chemist, bleacher, and photographer, has of late
been admitted into our materia medica; and as they are not, like Dr. Churchill's
hypophosphites, recommended as specifics against one special disease, but as
.useful remedies for a great variety of morbid conditions, acute as well as chronic,
local as well as constitutional, they are likely to fulfil at least part of their pro-
mises, and deserve the more to be thoroughly tried, as they can be administered
even in large doses without any danger to the system. Some of the hyposul-
phites have already been tried in France ; but the sulphites are, as far as I am
aware, quite new in medicine. Their active principle is, in all probability, sul-
phurous acid, and its modus agendi is explained by an alleged decomposition of
the salt, the subsequent change of sulphurous acid into sulphuric acid at the
expense of the blood or the tissues ; and the final formation of sulphates, which
can always be traced in the urine, about twelve hours or even sooner after the
administration of the drug. Whether the action of these salts, or of the sul-
phurous acid they convey, be called antiseptic, or antifermentative, or disinfect-
ing, is of no importance. They are, at all events, likely to have alterating
effects, and the results of therapeutical experiments, as far as they are extant,
have confirmed this d 'priori supposition. The following is the experience of
Professor Polli concerning these new remedies : —

1. The sulphite of soda is soluble in water, and of an unpleasant taste ; dose
3j to ^ij per diem. A solution of one to ten grains may be used for lotions.
No. LXXXYIIL— Oct. 1862. 83

514

Progress or the Medical Sciences.

[Oct.

The bisulplaate of soda is also soluble, but its taste is so bad that it should
only be used externally, dissolved in ten parts of water.

The hyposulphite of soda is soluble, and of tolerable taste. Dose gr. x to 9ij
per diem.

2. The sulphite, bisulphite, and hyposulphite of potash are all soluble; but
only the last-mentioned should be administered internally, in doses varying from
gr. V to 3j per diem.

3. The sulphite of magnesia is the most soluble of all sulphites, the richest in
sulphurous acid, and the least unpleasant to the taste, ^ss to ^ij may be given
per diem, in ten grain doses.

The bisulphite and hyposulphite would be equally suitable for internal use,
but are better dispensed with, as they are, by air and moisture, rapidly changed
into sulphite of magnesia.

4. The sulphite of lime requires 800 parts of water for solution, while the
bisulphite and hyposulphite are easily soluble. These three salts have been
given in doses of only gr. iij to gr. vj per diem. Signor PoUi recommends them
in the purulent stage of consumption, where they are, according to him, apt to
check the absorption of purulent matter and to favour the cicatrization of
vomicae. This seems a kind of ex cathedra argument, but the remedy will pro-
bably prove as good as any other.

5. Lastly, the sulphite, bisulphite, and hyposulphite of ammonia, are all very
deliquescent, and of a pungent taste. They are easily changed into sulphates,
and can only be used externally.

All the sulphites which can be administered internally may be given either
in powder, mixed with sugar, and flavoured according to taste, or in edulcorated
solutions. The sulphite of magnesia and the three salts of lime are preferable
for internal, the others for external use. The hyposulphites in general have
been found to act most slowly, inasmuch as they must first pass into the state
of sulphites. They are rapidly decomposed by vegetable acids, but not altered
by acetic acid, whence Signor Polli concludes, that during their use all kinds of
fruit should be avoided, while vinegar may be allowed.

Having fiirst tried these salts in animals, and having found that dogs can take
as much as two or three drachms a day without showing any symptoms of dis-
turbed health, Professor Polli commenced a series of clinical experiments, which
were imitated by a few other practitioners, in a great variety of cases which
hardly admit of classification. Although Signor Polli endeavours to make out
that in all these cases the efficacy of the salts is due to the antifermentative
action of the sulphurous acid they convey to the system, it remains still to be
shown whether so many different diseases can fairly be attributed to the ol^
bugbear of fermentation. But, leaving apart this dogmatical side of the ques-
tion, I shall simply enumerate the principal diseases in which the sulphites have
hitherto been given with success.

1. Eruptive fever, smallpox, scarlatina, and measles, especially their malig-
nant forms; erysipelas, zoster, acute pemphigus.

2. Chronic eruptions require the additional application of lotions or oint-
ments, made of hyposulphite of soda. As an excellent prophylactic remedy
against contagious diseases of the skin, Signor Polli recommends the hyposul-
phites, especially that of soda, of which he gives from forty to sixty grains daily.
He lays great stress on the sluggishness with which these salts undergo their
chemical changes within the intestinal canal ; and his belief in their prophy-
lactic powers seems to be chiefly founded on this fact. But as nothing short of
statistics can save the reputation of a prophylactic, we must wait for further
experience before the value of these new remedies can be considered as fully
established.

3. Ulcers. — Professor Polli excludes scrofulous and syphilitic sores, but it
appears that other practitioners have tried the sulphites even in such cases, and
not without success. I cannot find a case of genuine primary chancre thus
treated. But an old sore, which had resulted from the opening of a bubo, has
most successfully been treated by Dr. Galligo with lotions of sulphite of mag-
nesia (1 : 20), the same remedy being also prescribed for internal use.

1862.]

Materia Medica and Pharmacy.

515

4. Gastric and rheumatic fevers. — For tlie so-called febris pituitosa of child-
ren, Signor Polli knows no better remedy than the sulphite of magnesia.

5. Absorption of purulent matter after surgical operations, nosocomial fever,
puerperal fever, inflammation of the lymphatic vessels and glands from cadave-
rous infection. In all these diseases the curative action of the sulphites has
been very striking, and has been further elucidated by a series of experiments
on animals, which have led to important results. It was found that after a
previous administration of sulphites, either given internally or injected into the
veins, animals resisted the action of purulent and even putrid matter subse-
quently introduced into their system. When the latter was injected first, and
sulphates given internally or injected afterwards, the deleterious action of the
poison could always be arrested, even when its first symptoms had already set
in. The effects are probably modified according to the quantities of matter
used. But if the facts just mentioned should be confirmed by further experi-
ence, these new remedies would have to be considered as most important addi-
tions to the therapeutical stock, especially of veterinary surgeons.

6. Acute rheumatism, miliary and typhoid fever, have also been treated with
sulphites ; but Signor Polli speaks less confidently of these cases.

7. I have already mentioned that the sulphite of lime is recommended in pul-
monary consumption, on account of its supposed tendency to produce cicatriza-
tion of vomicse.

If. lastly, Professor Polli invites his medical brethren to try his sulphites also
in cholera and intermittent fever, he evidently weakens his cause, although we
may excuse excess of paternal partiality for a new-born, remedy which bids fair
to have a long and brilliant career, and which certainly deserves as much con-
sideration as the podophylline and other children of fashion.

All sulphites, used for therapeutical purposes should be prepared by the phar-
macist, as those hitherto met with in commerce are far from pure. Signor Polli
found that a compound sold to him as sulphite of potash contained sulphate of
potash, clay, and some other insoluble matter ; while a thing sold as sulphite of
lime contained quicklime, carbonate and sulphate of lime, chloride and sulphuret
of calcium, and some resinous matter. In order to avoid the possibility of mis-
takes, I will add that the sulphites here spoken of are represented by the formula
:\[0 + SO2, the bisulphites by MO + 2 SO2, and the hyposulphites by MO +
S.2O2. without any reference to the additional multiples of water. — Med. Times
and Gazette, June 14, 1862.

11. Glycerole of Tar (Tar Plasma). — A combination of glycerine and tar has
been used recently in skin affections instead of the tar ointment of the Pharma-
copoeia. The advantages seem to be that the glycerine compound is more rea-
dily absorbed, and less difficult to remove by washing. Mr. Brady states that
he has not been able to find a formula for the preparation in question, neither
. can he learn that any published one exists, and would, therefore, propose the
following, as yielding an unexceptionable product. The strength is the same as
that of the unguentum picis liquidum, P. L. : Price's glycerine, six oz. weight ;
tar, six oz. weight; powdered starch, two drachms. Warm the glycerine, stir
in the starch, add the tar, and raise the mixture rapidly to the boiling point.
Strain through a cloth, if necessary, and stir while cooling. The mere mixture
of glycerine and tar heated in a water-bath, gives on cooling a spongy mass, the
pores of which are filled with glycerine; after standing some time, complete
separation takes place. Tragacanth, acacia, soft soap, and many other things
have been tried as substitutes for the starch, but none of them with so good
result. Made according to the above formula, glycerole of tar is a dark brown
mass, perfectly smooth, in consistence somewhat softer than the ointment. —
Duh. Med. Press, Sept. 10, 1862, from Pliarm. Journ.

516

Progress of the Medical Sciences.

[Oct.

MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL

MEDICINE.

12. Suspended Animation. — The Royal Medical and Chirurgical Society some
time since appointed a committee to inA^estigate and report on this subject.
This committee has recently (July 1) made an elaborate and highly interesting
report, of which we lay before our readers a brief summary.

The inquiry was conducted — By means of experiments upon living animals ;
by means of experiments upon the dead human body. In investigating anew
the subject of apnoea by means of experiments on the lower animals, it seemed
expedient to observe, in the first place, the principal phenomena of apncea in its
least complicated form — namely, when produced by simply depriving the animal
of air. The principal facts to which attention was directed during the progress
of the apnoea thus induced were — The duration of the respiratory movements ;
the duration of the heart's action. The duration of the heart's action was ob-
served— [a.) In relation to the duration of the respiratory movements. (6.) In
relation to the time after the stoppage of the breathing. From the experiments
performed, it appeared that in the dog the average duration of the respiratory
movements after the animal has been deprived of air is 4 min. 5 sec, the ex-
tremes being 3 min. 30 sec. and 4 min. 40 sec. The average duration of the
heart's action is 7 min. 11 sec, the extremes being 6 min. 40 sec. and 7 min. 45
sec. From these experiments, it appears that on an average the heart's action
continues for 3 min. 15 sec after the animal has ceased to make respiratoiy
efforts, the extremes being 2 min. and 4 min. respectively. Rabbits on an ave-
rage ceased to make respiratory efforts in 3 min. 25 sec. Their heart's action
stopped in 7 min. 10 sec. ; consequently the interval between the last respiratory
effort and the cessation of the heart's action was 3 min. 45 sec.

The next question investigated was — The period after the simple deprivation
of air at which recovery is possible, under natural circumstances, without the
aid of any artificial means of resuscitation. The experiments performed led to
the conclusion that a dog may be deprived of air during 3 min. 50 sec, and
afterwards recover without the application of artificial means ; that a dog is not
likely to recover, if left to itself, after having been deprived of air during 4 min,
10 sec. The force of the inspiratory eflorts during apncea was observed in the
experiments to be so great that it was determined to measure them. They were
found to be capable, in the dog, of raising a column of mercury four inches. It
appeared, moreover, that their force increases up to a certain period. In other
experiments, plaster of Paris, and even mercury, were thus drawn upwards into
the minute bronchial tubes. It is easy to understand, therefore, how foreign
bodies may be drawn into the lungs in cases of drowning, and the importance of
this fact in the consideration of the pathology and treatment of apnoea.

The committee next passed on to the subject of drowning. The first question
investigated was — For what period can an animal be submerged, and yet recover
without the aid of artificial means ? It was found as the result of numerous
experiments on dogs that, in striking contrast to the previous ones, one and a
half minute's immersion in water suffices to destroy life. Other experiments
satisfactorily showed that the difference of time between simple apnoea and that
by drowning is not due to submersion, or to depression of temperature, or to
struggling, but that it is connected with the fact that in the one case a free
passage of air out of the lungs, and of water into them, is permitted ; in the
other, the exit of air and the entrance of water are prevented. There can be
no doubt, from other considerations put forward, that although both these cir-
cumstances are concerned in producing the difference observed, yet that it is
mainly due to the entrance of water and the effects thereby produced.

The treatment of apnoea was next considered. For conclusions respecting
artificial respiration the Committee refer to the second portion of the Report.
Many other methods of resuscitation which have been recommended were em-
ployed, including actual cautery, venesection, cold splash, alternate application

1862.]

Medical Pathology and Therapeutics.

511

of hot and cold water, galvanism, puncture of the diaphragm. Although some
of the above means were occasionally of manifest advantage, no one was of such
unequivocal efficacy in a sufficient number of cases as to warrant the Committee
in specially recommending its adoption. The experiments upon the dead subject
were made with a view to determine the value of the various methods which
have been employed for alternately compressing and expanding the cavity of the
chest in such a manner as to imitate the natural movements of the thoracic
walls in breathing. The following methods have been investigated : 1. Pressure
exerted by the hands on the anterior wall of the thorax, the body being in the
prone posture. Such pressure has for its object to expel a portion of the air
contained in the chest; on relaxing the pressure the chest expands and air
enters. 2. The postural or so-called "ready" method, described by Dr. Marshall
Hall, which consists essentially in "turning the body gently on the side and a
little beyond, and then briskly on the face alternately;" and in making pressure
along the back of the chest each time the body is brought into the prone posi-
tion. 3. The method of Dr. Silvester, in which the action of the pectoral and
other muscles passing from the shoulders to the parietes of the chest in deep
inspiration is imitated. An inspiratory effort is produced by extending the arms
upwards by the sides of the head; on restoring them to their original position
by the side of the body, the expanded walls are allowed to resume their previous
state, and expiration takes place, the quantity of air expelled being in proportion
to that which had been previously inspired. It being necessary to measure the
flow of air in and out of the respiratory cavity under conditions of pressure
closely resembling those which exist in natural respiration, no means of mea-
surement could be used which, in its working, would offer any appreciable resist-
ance to the passage of air. With this consideration in view, an instrument
designed by Dr. Sanderson was employed. (The instrument was exhibited to
the Society.)

Ge7ieTcd results.- — 1. As regards the volume of air which can be expelled
from the thorax by compression of its walls, and inspired by the elastic expan-
sion consequent on relaxation of the pressure, it was found— (a.) That pressure
by both hands on the lower third of the sternum in the adult male subject usually
displaced from eight to ten inches of air. The pressure actually exerted amounted
to about thirty pounds. It was. therefore, not greater than might be safely
applied to the living subject. The volume of air expelled varied from eight
cubic inches to fifteen cubic inches. (&.) That pi-essure made in the same man-
ner on the upper part of the sternum usually displaced two or three cubic inches
less than pressure on the lower part, (c.) That pressure exerted by one hand
on the upper part, by the other hand on the lower part of the sternum, pro-
duced about the same results as were observed in a. In this case the whole
amount of pressure did not exceed that exerted in a. {d.) That the pressure of a
weight laid on the lower third of the sternum produced similar results according
to its amount, [e.) The lateral pressure exerted on the ribs or costal cartilages
of both sides simultaneously was in no instance more effectual. (/.) That com-
pression by a broad bandage encircling the chest, the ends of which were crossed
over the sternum, and drawn in opposite directions by two persons, produced no
greater effect than pressure with the hands on the sternum or sides. 2. As re-
gards the whole amount of exchange of air produced by the method of Dr.
Marshall Hall, " to imitate respiration," it varied much, according as the subject
was favourable or the contrary; sometimes not exceeding a few cubic inches,
but never exceeding fifteen cubic inches. 3. As regards Dr. Silvester's method,
it was found that, on extending the arms upwards, a volume of air was inspired
into the chest, which varied in different subjects, from nine to forty-four cubic
inches, and it was observed that the results obtained in successful experiments
on the same body were remarkably uniform, in which respect, as well as in their
amount, they contrasted with those obtained by the method of Dr. M. Hall. On
restoring the arms to the side, the quantity of air expelled was generally nearly
equal to that previously inspired, occasionally less.

In the treatment of apnoea generally, the comniittee offer the following sug-
gestions : That all obstruction to the passage of air to and from the lungs be at
once, so far as is practicable, removed; that the mouth and nostrils, for exam-

518

Progress of the Medical Sciences.

[Oct.

pie, be cleansed from all foreign matters or adhering mucus. That in the ab-
sence of natural respiration artificial respiration by Dr. Silvester's plan be
forthwith employed in the following manner : The body being laid on its back
(either on a flat surface, or, better, on a plane inclined a little from the feet
upwards), a firm cushion or some similar support should be placed under the
shoulders, the head being kept on a line with the trunk. The tongue should be
drawn forward so as to project a little from the side of the mouth. Then the
arms should be drawn upwards until they nearly meet above the head (the ope-
rator grasping them just above the elbows), and then at once lowered and re-
placed at the side. This should be immediately followed by moderate pressure
with both hands upon the lower part of the sternum. This process is to be
repeated twelve or fourteen times in the minute. That if no natural respiratory
efforts supervene, a dash of hot water (120'^Fahr.) or cold water be employed,
for the purpose of exciting respiratory efforts. That the temperature of the
body be maintained by friction, warm blankets, the warm bath, etc.

In the case of drowning, in addition to the foregoing suggestions, the follow-
ing plan may be in the first instance practised : Place the body with the face
downwards, and hanging a little over the edge of a table, shutter, or board,
raised to an angle of about thirty degrees, so that the head may be lower than
the feet. Open the mouth and draw the tongue forward. Keep the body in
this posture for a few seconds, or a little longer if fluid escapes. The escape of
fluid may be assisted by pressing once or twice upon the back. (Signed) —
C. J. B. Williams, Chairman; W. S. Kirkes, George Harley, J. B. Sanderson,
C. E. Brown-Sequard, H. Hyde Salter, E. H. Sieveking, ex officio ; William S.
Savory, Hon. Sec.

13. Tivo Cases of Extensive Arterial Ohstruction from Separated Cardiac
Vegetations, followed hy Gangrene and Death. — Dr. Goodfellow read before
the Royal Medical and Chirurgical Society (June 24) two cases of this charac-
ter. The extent to which the plugging took place, the number of vessels in-
volved, the morbid changes in and around the coats of the vessels at the seat of
obstruction, and the consequences which ensued, appeared to the author to give
a peculiar interest to them. In both cases vegetations of considerable size had
formed on the mitral valve and surrounding surface of the endocardium. Some
of these had become detached, and caused obstruction to the circulation in
several of the large arterial trunks ; coagula formed around them, and complete
occlusion followed. The symptoms were well marked — namely, pain, intense
and agonizing, at the seat of obstruction, and coldness and numbness at the
distal extremities of the affected limbs, speedily followed by dry gangrene. In
the first case the evidences of occlusion were observed about a month before the
fatal event, and about seven days prior to the appearance of gangrene. In the
second case the interval between the evidence of obstruction and the appearance
of dry gangrene was shorter; the pathological changes in and around the walls
of the arteries at the seat of obstruction were less extensive. The first case
was that of a woman, aged 30, who had had an attack of acute rheumatism
twelve years prior to her admission into the hospital. The heart was damaged
during that attack. She, however, was enabled to follow her usual occupation,
with occasional interruptions, up to a short period before the appearance of the
symptoms denoting obstruction. The second case was that of a girl, aged 17.
She had had an attack of acute rheumatism about three years before, compli-
cated with pneumonia, but not with heart affection. Another attack of rheu-
matism occurred about eighteen months afterwards, which was complicated with
endocarditis. From the time of this attack to the period of her seizure with her
last fatal illness, she suffered considerably from dyspnoea and frequent and severe
pain in the prsecordial region. — Med. Times and Gaz., July 5, 1862.

14. Epidemic of Typhoid Fever Dependeiit upon the Use of Impure Water. —
During the autumn of 1860, there prevailed in the convent of the Sisters of
Charity, i"n Munich, an epidernic of abdominal typhus, which was the more re-
markable because at that time there were only a very few isolated cases scattered
through the town. From the 1st of June till the beginning of September, there

1862.] Medical Pathology and Therapeutics.

519

were only two cases of typhoid fever in the convent; but from the 19th of Sep-
tember till the 4th of October, when the population of the convent consisted of
a hundred and twenty persons, thirty-one of the sisters became rapidly affected,
one after the other. Some presented gastric symptoms, others were attacked
with regular typhoid fever. Of the fourteen cases of typhoid fever, four proved
fatal.

The attention of the medical profession was especially called to this state of
matters, because the sanitary state of the town was at that time very satisfac-
tory, and typhoid fever was very rare. It was evident, then, that the cause of
this epidemic must be look for in local circumstances ; and, after a careful
examination, it was discovered that the water, used as drink by the inmates,
was mixed with substances in a state of putrefaction, and that it constituted
the cause of the epidemic. The local circumstances were the following : The
convent is situated beside the general hospital. In the spring of 1860, a well
was dug in the latter, having a depth of twenty feet. This well was distant
only two feet from the laundry in which the clothes of the patients were washed,
and was surrounded by the openings of five drains, intended to absorb the
water which ran off from the laundry, and connected with one another by gut-
ters, from which the water was insensibly filtered into the surrounding soil.
This water was turbid, had a disagreeable odour, and contained an abundant
sediment. As the drains were only twenty or thirty feet from the well, the
water in the latter was contaminated by that in the drains. To demonstrate
this fact, the contents of the drains and the water of the well were submitted to
a careful microscopic examination by Dr. Hessling, a skilful microscopist. He
found, in the sediment of the water from the drains, various kinds of matter, of
animal and vegetable origin, in a state of decomposition : some could still be
recognized by their original forms, but the greater part constituted only a mass
of detritus. This detritus was in the form of a flaky coagulum of a dark-green
colour, forming little masses, some of which contained inorganic matters, such
as sand, particles of lime, etc., which seemed to have constituted the nuclei.
Both the water and the sediment contained a large quantity of carbonate of
lime, and on the addition of a little sulphuric acid, a strong odour, resembling
that of rotten eggs, was disengaged ; the same phenomena took place even with
the small objects which were submitted to microscopic examination. In addi-
tion, there were observed organic elements of new formation, such as algse,
spores, vibriones, and monades, which moved rapidly about in the field of vision.
The water from the well deposited no sediment ; nevertheless, on examining it
microscopically, the same elements were observed as in the water coming from
the drains, but in a very diluted state, especially as concerns the flaky coagula,
the spores, and the vibriones.

It was consequently demonstrated that the water of the well had been con-
taminated by the contents of the drain. Professor Pettenkoffer, who made a
chemical analysis of the water of the well, discovered in it a much larger quan-
tity of organic matters, of lime, and of nitrates, than is contained in ordinary
drinking water.

The water of the new well habitually supplied the requirements of the laundry.
Between the 17th and 28th September, the time when the epidemic commenced,
the water was conducted by pipes into the bath-room and kitchen of the hos-
pital and convent, because, as repairs were being carried on in the bath-room,
these establishments no longer received a sufficient supply of water. It was
recommended that this water should only be employed for baths, for washing,
and for the kitchen, and that the water which was to be used for drinking shoufd
be furnished from two wells situated in a court intermediate between the hospital
and the convent. Nevertheless, although the attendants in the convent had
been sufficiently warned, it appeared, after a careful investigation, that the
water which was carried in the evening from the kitchen into the bedrooms of
the sisters to be used for the toilette, had been also used for drinking; and all
the persons who became ill, acknowledged that they had drunk this water.

If it be considered that the epidemic commenced at the very time when this
water, which contained putrefying organic matters coming from the dirty linen
of the patients, began to be drunk, we are authorized in concluding that the

520

Progress of the Medical Sciences.

[Oct.

cause of the typhoid affection existed in the poisonous properties of the water —
a conclusion which is still farther justified by the fact that the epidemic ceased
as soon as the water in question ceased to be employed for drinking. — Edinh.
Med. Journal, June, 1862, from Nederlandsch Tijdschrift voor GeneesJcunde.

15. Diabetes with Spinal Irritation. By Dr. E. A. Kunkler. — The subject
of this case, was a man, 26 years of age, who had been the subject of diabetes for
seven months. Notwithstanding the use of morphia, iron, bitters, exclusively
animal diet, &c., he got worse ; the emaciation, thirst, want of sleep, frequent
epistaxis being excessive. After consulting numerous physicians without benefit,
the relater of the case, bearing in mind the hypothesis of Scharlan, that the
origin of the disease was to be found in the vertebral column ; and the discovery
by Bernard, that irritation of the fourth ventricle of the brain caused the appear-
ance of sugar in the urine and blood, thus connecting the disease with some
derangement of the nervous system ; and moreover finding that in this case the
superior part of the dorsal portion of the spine was tender at many points, ap-
plied a certain number of cupping-glasses. Their application was followed by a
disappearance of this morbid sensibility, but there was no abatement of the dis-
ease itself. Immediately, however, after a blister upon the neck, the presence
of sugar and the unusual excretion of the urine ceased most unexpectedly, as if
by enchantment. A slightly disagreeable sensation, which hitherto the patient
had experienced at the lower part of the brain, also ceased at once. After con-
tinuing for ten or twelve days blisters upon the neck and behind the ears alter-
nately, the affection had entirely and permanently disappeared, and this in spite
of a varied diet.

The particulars of the above case were sent to M. Bernard, with the hope
that as Paris offered more cases of diabetes than the locality where Dr. Kunkler
lived (Placerville, California), he would give the plan of treatment an extended
trial.

The quoter of the case in U Union Medicale recalls to notice the recital by
Becquerel of an instance in which glucosuria occurred in a case of acute mye-
litis, and in a case of spinal meningitis with tumour of the pia mater and soften-
ing and cyst of the cerebellum ; also by Lebert, of diabetes in a hemorrhagic
affection of the spinal cord ; and by Scharlan, of the post-mortem examination
of two cases of diabetes, in which softening of the cord, with other changes, were
found. He wisely suggests that the cure of diabetes by the means above related,
must not always be looked for, inasmuch as although generally being developed
under the influence of the nervous system, its modes of origin are very various.
—B. and F. Med-Chir. Rev., July, 1862, from V Union Med., July 29, 1861.

16. Diphtheria and its Sequelce. — Dr. James Begbie has published [Edinh.
Med. Journ., May, 1862) some interesting observations on diphtheria. His
cases tend to confirm the views generally entertained in regard to the nature of
diphtheria, and go to establish: —

1st. That it is a constitutional disorder having the character of fever, running
a definite course, and bearing a closer affinity to scarlatina and typhoid fever
than to any other specific disease.

2d. That its local manifestation is chiefly observed on the mucous membrane
of the mouth and throat ; the tonsils, uvula, and palate with the pharynx being
first affected; but that it has a tendency to spread to the adjoining passages,
and is particularly prone to invade the larynx.

M. That this local disease is of the nature of inflammation of asthenic cha-
racter, with exudation of lymph in the form of pellicle.

4:th. That the disease is contagious, and that youth and consanguinity power-
fully predispose to it.

bth. That it is fatal from the severity of the general disorder, or from the
exudative inflammation invading the larynx, and causing suffocation; or that
death may result from the nervous disorder supervening in the form of paralysis.

And, lastly, that as we have no specific remedy for diphtheria, the disease and
its sequels m\ist be treated on the general principles which regulate our practice
in fever and in inflammation, and in nervous disorders of asthenic character.

1862.]

Medical Pathology and Therapeutics.

521

17. Influence of Temperature on Yellow Fever. — Dr. Archibald Smith (for
many years resident in Peru) stated at a late meeting (June 2) of the Epidemi-
ological Society, that he had noted all the essential symptoms of yellow fever at
an elevation of 11,250 feet, with a temperature in the wet season of 62^ within
doors, with little variation day and night. At this temperature the disease lost
none of its energy. In 1853 yellow fever appeared simultaneously on both sides
of the Andes, and in 1854 assumed its most malignant character as well by the
seaboard as on the hill-land. It was shown that these epidemics were of one
generic nature. The yellow fever symptoms became modified gradually into the
typhous or typhus, in the transit from the Pacific shores to higher and still
higher regions of the Andes. In the warmer inland valley, as, e. g., in the sugar-
growing district of Abancay, the fever, which near the snows of the Cordilleras
was metamorphosed from the typhus-icterodes of the coast into a form which,
in a great measure, represented ordinary British typhus, was again reinstated
with its most aggravated coast symptoms of yellow fever, such as intense frontal
headache, dark sanguineous vomiting or evacuations, subcutaneous hemorrhage
in form of large, dark maculae, nasal hemorrhage, intense yellow colour of the
skin, and the most extreme prostration of vital forces. In the Sierra it was
propagated slowly from place to place, and from person to person. It was all
but incurable in the dark and crowded huts, but yielded readily in a great ma-
jority of cases to early treatment, under the advantages of pure air and hygiene.
Left to itself in the hovels of the Indian iDoor, it was prodigiously fatal. — Med.
Times and Gaz., July 19, 1862.

18. Clinical Eesearches upon Auscidtation of the Head. By Henry Roger,
M.D., Prof. Fac. Med. Paris. — It is well known that the first application of the
discovery of Laennec to the diagnosis of diseases of the brain was made by
Dr. Fisher, of Boston. In 1833 this physician communicated to a learned so-
ciety a memoir upon the cephalic belloius sound, and transmitted his interesting
researches to the American Journcd of Mediccd' Science, Aug. 1838. "Auscul-
tation," said Dr. Fisher, "may be as useful in the symptomatology of afiections
of the brain as it is in those of the chest, and may furnish a pathognomonic
sign of these diseases."

After having traced the rules of cerebral auscultation, and indicated the nor-
mal sounds which reach the ear when applied to the head, and having distin-
guished those which come from the nasal fossse..and which belong to respiration
and phonation, as well as those which proceed from deglutition and from the
head itself; after having distinguished all these from abnormal sounds. Dr. Fisher
considers the cephcdic souffle in diseases of the encephalon. He mentions,
among other affections of which an abnormal bruit is one of the symptoms,
chronic hydrocephalus, cerebrcd congestion, either simple or resulting from dis-
ordered dentition or hooping-cough, acide ijiflammation of the encephcdon or its
meinbranes, abscess of the brain and induration of that organ.

Dr. Whitney went even further than his colleague in his opinions with regard
to the symptomatological value of the cephalic soufSe [American Journcd of
Mediccd Science, Oct. 1843). To the affections mentioned by Dr. Fisher — cerebral
congestion, meningitis, &c., in which the stethoscopic phenomena were present,
he adds scirrhous transformation of the cerebellum, and mechanical compression
of the brain. He says, moreover, that he perceived a cerebrcd cegophony in
hydrocephalus, a bruit similar to the ccdarrhcd fremitus in aneurism of the arte-
ries at the base of the brain, and finally he points (and with reason, in certain
cases) to the existence of a cephalic souffle. m ancemia of the brain and also in
chlorosis.

Notwithstanding the labours of these two American authorities, each of whom
confirmed the observations made by the other, and in spite of results which
generally agree, and which seem to have the testimony of numbers — for the
facts in their memoirs count by hundreds — cerebral auscultation, which promised
to throw an unexpected light upon a very obscure point in pathology, met with
but little favour. The European medical journals confined themselves to incom-
plete analyses and short extracts; while but few practitioners thought it their
duty to repeat the experiments necessary for a criticism of the facts which had

522 Progress of the Medical Sciences. [Oct.

been stated by our American brethren, as if tliey mistrusted a discovery coming
from sucli a distance.

In tlie year 1841, in the first edition of the Traite Pratique cl' Auscultation,
mention was made of the observations of Drs. Fisher and Whitney; but the
experiments to which M. Barth and I devoted ourselves for testing their truth,
though certainly not very numerous, only gave us negative results. After having
searched in vain to discover a cephalic souffle in certain cerebral affections, and
having been unable, in twelve or fifteen cases of meningitis, to hear any such,
while the American doctors declared it to be present in all ; strengthened besides
in our scepticism by the silence maintained by MM. Andral and Bouillaud upon
auscultation of the head, and by the equally negative observations of MM.
Fournet and Yernois, in nine or ten cases of meningitis, and of Professor Piorry,'
we thought it right at that time, and in subsequent editions of our work, to
express doubts of this new application of the stethoscope, and were led to dis-
pute, if not the reality, at least the importance of auscultation of the brain.

Still I always regretted this summary condemnation of the undoubtedly con-
scientious labours of two professional brethren. That results stated in America
as certain should be absolutely and generally denied in Europe seemed not a
little extraordinary ; and we must either suspect the mode in which the physi-
cians on the other side the Atlantic made their observations, or confess that in
this hemisphere we were deaf to sounds distinctly heard in the other. Shall we
say with Harvey's adversary, the old Venetian physician, ''quern nos surdastrz
audire non possumus" — "in Europe people are deaf; they only hea,r that in
America 'tantum modo in America exauditur.' "

As the only means of deciding the question was by making more minute clin-
ical observations, I devoted myself patiently to this difficult task, and began
afresh the study of cerebral auscultation. My researches were almost exclu-
sively among children,^ because it is chiefly among them, when at the breast,
that Drs. Fisher and Whitney said they heard the stethoscopic phenomena, the
discovery of which they announced; and because the difficulty of diagnosing
diseases of the brain is greater in childhood than in later life, a greater interest
belongs to the progress which symptomatology would make in this department.
I may add in passing that it is only among children, whether subject or not to
cerebral disease, that auscultation of the brain is likely to be of use; for beyond
a certain age, or beyond a certain period of early childhood, the most practised
ear applied to the cranium cannot detect morbid cephalic bruits.

Since I began collecting the observations which form the subject of this me-
moir, several authors have been similarly engaged in cerebral auscultation, among
others MM. Rilliet and Barthez. and M". Hennig. head of the Children's Hospital
at Leipsic. The first, in their admirable work (2d edit., vol. ii. pp. 158-9). make
some remarks on the cephalic souffle in cases of hydrocephalus and in rachitis ;
I shall have occasion to quote the passage where they speak of this bruit under
the head of the diagnosis of these afiections. The German author has written
a monograph upon this subject, and in a pamphlet of not less than thirty pages
{Arcliiv fur pliysiologische Heilkuncle. Stuttgart, Aotit 1856) he reproduces,
with annotations and additions, the inaugural thesis of Dr. Wirthgen [De stre-
pitu qui in ca'pite auficuUando auditur, Leipsic, 1855), which, indeed, appears
to owe its birth to him, and in which he successively studies the normal and
abnormal bruits discovered by cerebral auscultation, the seat of those bruits,
the age at which they are heard, their physiology and pathology, and especially
the mechanism of their formation, and from these he deduces the results which
the physician may expect to find in practice. I had completely devoted myself
to this study before I became acquainted with the researches of M. Hennig, and
we shall see, by the details of my observations, how far my conclusions agree
with his.

Perhaps the admirable work of the Leipsic physician is faulty from a want of
method and perspicuity, of which French readers complain greatly in the writ-

1 Traite de pathologie iatrique, tom. viii. p. 353.

2 I have never been able to detect any cephalic bruit among adults, either in
apoplectic patients or young chloro-an;Bmic females.

1862.]

Medical Pathology and Therapeutics.

523

ings of the learned German author. M. Hennig does not give with sufficient
clearness the details from which he drew his deductions, nor his mode of pro-
ceeding in collecting facts ; the number of cases from which he decides (and
they do not appear to be very numerous) are not indicated with precision ; all
this necessarily diminishes the value of his statements.

In order that I may not incur the reproach just cast upon the German author,
I may say that the conclusions which are recorded in this paper were drawn
from an examination and comparison of a very considerable number of observa-
tions, their total being nearly 300 ; at first they were gathered from cases selected
among children whom I thought were affected with cerebral disease, or who were
the subjects of rickets; then (having determined the existence of a cephalic
souffle among children of healthy appearance) I afterwards examined all cases
indiscriminately, whether in the wards of the Hospice des Nouveaux Nes, the
Hopital des Enfants, or in private practice.

Plan of the Memoir. — Having made these preliminary observations, we come
now to the study of facts, and after having traced out the rules which facilitate
auscultation of the head, I shall point out what 'physiological hruits the ear dis-
covers when applied to the cranium; and in a third chapter, the longest and
most important, morbid bruits will be specially considered.

Section I. Rules for Cerebral Auscultation. — When a patient is submitted
to stethoscopic examination the most convenient position is the horizontal, with
the head placed upon a pillow slightly raised; this may be inclined to different
sides, according as it is desirable to examine the occipital, frontal, or temporal
regions, &c.

In examining an infant at the breast, it should be seated on the knee of its
mother or nurse, and the head should, if possible, be held steadily, either by the
hands placed softly on either side, or by leaning it against the mother's breast.
If the patient be in a comatose condition from some cerebral affection, auscul-
tation will be easily performed. It becomes difficult when the child cries or
moves about, which is usually the case ; we must then try to quiet it by suckling
and auscult it while it is at the breast, the bruit of deglutition being no obstacle
to the recognition of morbid cephalic bruits.

If the examination be impossible while awake, it must be abandoned till an
attempt can be made in quieter moments, or we may make the attempt during
sleep, which is generally sufficiently profound not to be disturbed by the exam-
ination of a physician.

The auscultation may be either direct or indirect. Dr. Fisher found the latter
the most convenient, the ear adapting itself exactly to the rounded or projecting
surface of the cranium. Care must be taken to prevent the rustling of the hair ;
also, as a matter of cleanliness, the child's head should be previously covered
with a napkin, which may serve at the same time to keep it more firm. Auscul-
tation, practised thus directly, possesses some advantages; whatever may be
the cries or agitation of the little patient, one always finds, in applying the ear
quickly and somewhat firmly to the middle of the anterior fontanelle, that we
catch, so to say, the sound of a cephalic souffle. But when the child is asleep,
or when it is willing to remain quiet, mediate auscultation is preferable ; it allows ,
the detection of the bruits with greater precision and exactness, and we may
also isolate them, so that those which are natural are not confounded with those
which are abnormfal.

For this purpose the ordinary stethoscope, which has been generally substi-
tuted for the primitive cylinder of Laennec,' answers perfectly; held as a pen
in writing, it should be applied over the different regions of the cranium, and
be kept fixed in the same way as for auscultations of the vessels of the neck.
M. Hennig recommends the employment of a flexible stethoscope, twenty-three
centimetres long, having for its middle portion a tube of vulcanized India-rubber.
This stethoscope is certainly preferable, for with it we can easily follow the
movements of the child during the examination.

On what regions of the head should the instrument be applied in order the
better to detect the physical phenomena? If Drs. Fisher and Whitney are cor-

1 Traite Pratique d'Auscultation, cinquieme edition, p. 19.

524

Progress of the Medical Sciences.

[Oct.

reel, the bruit of the cephalic soufflei is so evident that it suffices to apply the
ear to any part of the cranium in order to discover it immediately; but our
experience does not bear out this assertion. It may be true that the bruits of
nasal respiration, and of deglutition, are perceptible over nearly the whole sur-
face of the head, but this is certainly not the case with the genuine cephalic
souffle, which we have most frequently heard in the region of the anterior fonta-
nelle, and still more plainly when we auscult directly over the fontanelle itself.
It gradually diminishes in intensity the further we remove from that point, which
appears to be the centre whence the bruit starts ; then gradually becoming more
feeble along the parietal or frontal sutures, it is completely lost further away,
the finest ear failing to discover any sound over the lateral surfaces of the cra-
nium and the occipital protuberances.

The physician who cannot count for long on the docility of his little patient
would do well, if he wishes to detect the cephalic bruit, at once to place his
stethoscope on the summit of the cranium over the depression corresponding to
the anterior fontanelle ; it is there, as we have said, that the abnormal bruit
exists in its greatest intensity, and the examiner, if he does not detect it at that
point, may dispense with any further investigation.

Section II. Physiological Bruits. — When we practice auscultation on the
top of the head of a healthy subject, different bruits are heard. ^

I. One is produced by the circulation of the air in the nasal fossae ; this is the
cephalic bruit of respiration mentioned by Dr. Fisher ; it is very intense and
harsh, and analogous to the laryngeal respiratory murmur; it coincides with the
respiratory movements, increasing in strength and frequency when these are
accelerated.

These characters are sufficient to distinguish it from other cephalic bruits ;
but in some cases of extreme dyspnoea the nasal respiratory bruit is so frequent
and quick that it might easily be mistaken for the cerebral vascular souffle of
which we have just spoken, and the two phenomena might be confounded were
it not for the close relation which the first bears to the movements of the thorax.

When the pituitary membrane is thickened or there is much secretion of mu-
cus, the respiratory cephalic bruit is transformed into a sibilant rhonchus, or
into a kind of coarse .crepitation ; the same physical conditions of the mucous
membrane exist as in bronchitis, and consequently the same rales are heard.

Nor is this all; in affections of the larynx, the bruits caused by the passage
of the air along the laryngo-tracheal tube are much drier and more or less pro-
longed, extending above into the nasal fossae as well as into the bronchial tubes
below, and the rhonchus or laryngeal hissing (similar to the bronchial rales)
everywhere heard is more perceptible in auscultation of the head than it is in
that of the chest. ^

With regard to the rales formed in the lungs, these are not heard from so great
a distance, and they escape stethoscopic examination when practised on the head :
in the very exceptional case of a young phthisical girl I was able to detect, by
cerebral auscultation, a loud gurgling which was produced in a cavity in the
subclavicular region.

II. If the child speaks or cries the vocal sounds are heard very distinctly,
and the ear, when applied to different parts of the cranium, perceives a very
remarkable resonance ; this cephalic 7'esonance may be compared to that which
is heard so loudly in the larynx, it has a nasal timbre which ^varies in different
individuals, it is always very piercing, the voice seeming to proceed from the
cranium.

III. Placing the stethoscope on the head, another peculiar bruit may be heard,
that of deglutition ; in new-born infants there is also that of suction. This bruit
is so singular and so readily recognized that there is no need to describe it. We
hear it more distinctly by direct than indirect auscultation, and in cases where
the nurse appears to have but little milk, and when consequently the child makes

> In treating here of auscultation of the head, I shall not consider aneurisms of the
larger art'eries of the brain nor diseases of the ear (see the work of M. Grendi in and
an admirable article by M. Menier, in the Traits pratique d'' Auscultation, 5th edit,
p. 562.)

1862.] Medical Pathology and Therapeutics.

525

frequent eflfbrts at suction without our being able to decide the fact of its having
swallowed anything, we may be able to determine this cerebral auscultation,
the bruit of deglutition comes very strongly upon the ear, and we are therefore
better able to appreciate the quantity of milk supplied and swallowed.

Such are the extrinsic bruits revealed by cerebral auscultation ; moreover, it
is not impossible to a practised ear to hear in some subjects, especially in cases
of palpitation, the two sounds of the heart propagated from the solid walls of
the cardiac region up to the head. In forty-two healthy infants five times I was
able with attention and patience to perceive the tic-tac of the heart in ausculting
over the cranium. In another case, I have been able to hear a strong bellows-
sound originating in the left auriculo-ventricular orifice ; but this last case was
exceptional. More frequently the cardiac sounds themselves escape observation
in auscultation of the brain; and we may, for greater simplicity in studying the
subject, omit the cardiac cephalic bruit, at least as it has been described by
Drs. Fisher and Whitney.

With much greater reason we shall contest the possibility of recognizing with
the ear the modifications which so-called cerebral diseases create: for example,
Dr. Fisher says he is able to discover in almost every case (thanks to his aptitude
for cerebral auscultation), the impulsive character of the pulsation which he
supposes to belong to apoplexy. These, however, are minutiae of such excep-
tional cases [rara non sunt artis), and tend only to embarrass without enriching
semeiology.

lY. Are we, then, to include in the physiology of this subject an intrinsic
bruit, the cephalic souffle, an essentially pathological phenomenon ?

On this point, those authors who have specially directed their attention to
auscultation of the brain are far from being agreed. With the American ob-
servers, the souffle is always abnormal, it is never a healthy phenomenon. Dr.
Fisher expressly says, "it depends always upon some cerebral affection." Dr.
Whitney equally insists upon the proposition, that auscultation never reveals
anything like a cephalic souffle in the normal condition.

M. Hennig, on the other hand, believes that the souffle belongs rather to a
state of health and, further, this bruit, which according to the American doc-
tors would be much more manifest as the cerebral affection became more marked,
would, according to the Leipsic physician, sometimes disappear in sick children,
to reappear with returning health.

If we seek among our own facts whether the American or German authors
are right, the first declaring that in the normal state the cephalic souffle is never
heard, and the second being of opinion that it is always heard ; we incline to
believe that both are equally wrong, and that these two exclusive opinions are
alike to be condemned. — London Med. Rev., July, 1862.

19. On the Transmission of Syphilis by Vaccination. — The very interesting
remarks which follow are from a clinical lecture delivered by M. Ricord, at the
request of M. Trousseau, in the H6tel Dieu, at Paris. They start from a case
then in the hospital : they end with an opinion upon the notorious case at Rivolta,
in which syphilis broke out in forty-six infants three weeks after vaccination.

A young woman, aged eighteen, was admitted on the 6th of December last
into the wards of the Hotel Dieu, for the treatment of catarrhal metritis and
granulating ulceration of the cervix. No syphilitic precedent whatever could
be traced in her history. An epidemic of smallpox having broken out while
she was in the hospital, all the patients liable to contagion were repeatedly
vaccinated. Although the girl presented unmistakable marks of previous suc-
cessful vaccination, she also underwent the operation. The lymph was sup-

' So we gather from several rather confused passages in his Memoir where ce-
phalic bruits are considered. " We have heard these bruits (M. H. does not say
which). on the head from the twentieth week to the sixth year. . . . These bruits
have been present in healthy children at the twenty-third week. " (Zoco cit. p. 413. )
"The souffle or hissing which is present in healthy children." (Ibid. p. 415.)
" These bruits are sometimes wanting in sick children, but reappear with convales-
cence." (Ibid. p. 413.)

526

Progress of the Medical Sciences. [Oct.

plied by a healthy infant, born in the wards, and vaccinated a few days before
with the virus distribflled at the Academy of Medicine ; three punctures were
made in each arm. Three children were also inoculated with the matter taken
from the same infant, and in all four the pustules were developed in the most
regular manner. In the young woman, on the contrary, the vaccine did not
take ; this was fully expected. She left the hospital, and was lost sight of for
a fortnight, when she returned to the H6tel Dieu, complaining of pain in one
arm. On examination of the part two pustules of ecthyma were found occupy-
ing the seat of two punctures. These were at first referred to a somewhat tardy
evolution of the vaccination, and perhaps to accidental friction. But the pus-
tules, deemed insignificant at first, gradually became larger and hard at the
base ; cervical and axillary adenitis set in, and, after an interval of five or six
weeks, a roseate eruption broke out over the entire body.

From the beginning, M. Trousseau strongly suspected the syphilitic nature of
the symptoms, but he was desirous of obtaining the opinion of M. Eicord, who
fully confirmed his conjecture.

It is an unquestionable fact, said this last-named physician, that this patient
bears on her arm a most distinct primary sore, an indurated and infecting
chancre, characterized by an indolent, convex tumour, ulcerated at the point
[ulcus elevatum), suppurating moderately, and supported on a broad, elastic
base, well limited at its margin, surrounded by uninflamed textures, and, as it
were, implanted in the healthy tissues. The present tumour is a fair specimen
of the infecting chancre in a state of transition towards the secondary stage,
and assuming the aspect of the mucous papula. Consider, in addition, the other
phenomena which have followed each other in rapid and regular succession, the
glandular enlargements of the axilla and neck, the headache and roseola, and
you cannot doubt but that the case before you is an unmistakable instance of
genuine secondary syphilis.

With regard to the origin of the disease, it is obvious that the punctures in
the arm have been the portals through which it has entered the system ; but it
is by no means so clear that the poison was introduced into these wounds together
with the vaccine-lymph.

M. Eicord does not reject this mode of propagation as absolutely impossible.
But in the estimation of facts which seem to establish such transmission, it is
necessary, said he, to distrust the evidence of our senses. It is only by taking
into account the obscurity which must necessarily surround a pathogenic inter-
pretation of an usually retrospective character, and carefully guarding against
the errors that a superficial observation may give rise to, that we can hope to
discover the solution of so important and intricate a problem. We have now
entered, he continued, upon a period of reaction against hitherto accepted doc-
trines, and if we do not take care, we will be almost inclined to pronounce a
man to be affected with syphilis if he has ventured, without an umbrella, in some
of the less reputable streets of this capital. M. Eicord then treated of the con-
tagiousness of constitutional syphilis, and ascribed it in most instances to the
infectious character retained by chancres, undergoing transformation into
secondary symptoms, or by mucous pajmlce, the earliest manifestation of the
general poisoning of the system, whether developed in situ by a metamorphic
change of the primary sore, or at a distance from the seat occupied by the latter.
However this may be, M. Eicord contends that the instances of propagation
of syphilis by the contagion of secondary symptoms, are far more unfrequent
than some authors have asserted. Syphilis is widely diSused, and were the con-
tagion of its constitutional manifestations as easy as has been affirmed, the nine-
teenth century would far outrival the fifteenth.

There may be perhaps some other vehicles of contagion besides the secretion
of chancre, and sometimes of a secondary sore ; this at least is not impossible,
but is not susceptible of peremptory demonstration in the present state of our
knowledge. An erroneous and hasty interpretation of obscure facts, in which
the true filiation of the symptoms has eluded detection, is, in M. Eicord's opinion,
at the bottom of all the mistaken theories and wandering speculations pro-
pounded on the subject. Thus, some men may escape infection though they
have communicated with a woman afiected with chancre, and others may be

1862.]

Medical Pathology and Therapeutics.

527

poisoned by one who herself is sound. Such cases are, of course, not obviously
intelligible at first, but the obscurity is 'easily cleared away by the now well-
known history of mediate contagion, by which we are taught that healthy females,
who after intercourse with diseased men are approached by persons in sound
condition, may transmit from the former to the latter the virus, themselves
escaping scatheless. M. Eicord here related several very curious instances
which illustrate and confirm in the most distinct manner the doctrine so perspi-
cuously laid down by M. Cullerier. On the other hand, it is unnecessary to ex-
patiate on the innumerable modes of conveyance of the virus from one person
to another. Every possible contact, every imaginable form of communication,
may generate chancre. M. Ricord once attended a magistrate afi"ecied with
indurated chancre of the eyelid, periauricular bubo, and secondary roseola. The
organs of generation were perfectly sound, but the patient acknowledged that
his hands had wandered into dangerous precincts, and that in rubbing his eyes
he had inoculated the virus into the eyelid. Is it entirely impossible that some-
thing of the same kind may have happened in M. Trousseau's patient? She was
lost sight of for a fortnight; the punctures in the arm induced some local un-
easiness, which she doubtless endeavoured to allay by scratching with her hand.
Now, who will say that that hand has constantly remained pure, or that the arm
may not have been exposed to any other suspicious contact? These are some
of the points which ought to be cleared up before vaccination can, with any show
of reason, be assumed to have caused the chancres observed in this instance.

The possible transmission of syphilis by the inoculation of the blood of per-
sons tainted with the virus has, however, been for some time before the public,
and derives considerable additional importance from the results recorded by M.
Viennois. In this memoir the author agrees with M. Rollet, that syphilis is not
transmitted by vaccine-lymph, but by the admixture of the latter with blood.
In a recent vaccination, which caused considerable sensation beyond the Alps,
it has likewise been contended, in order to account for the propagation of syphilis,
that blood oozed out, together with lymph, from the pustules of the child who
supplied the matter, and that the lancet of the operator was therefore charged
with a mixed fluid of deleterious nature.

M, Ricord, while admitting the truth of these facts, rejects the interpretation
which has been offered.

It is a remarkable circumstance, said he, that as soon as the generating poison
of syphilis has penetrated into the system, it is. fundamentally modified. It be-
comes undiscoverable to chemical analysis, or to microscopic research, and
utterly loses its distinguishing character of reproducing a pustule similar to that
in which it was originally generated. Were it otherwise, in a person tainted
with syphilis, the most trifling wound would be liable to assume the aspect of
chancre, from contact with the blood escaping from the lacerated vessels.
Nothing of the kind is ever observed. M. Ricord has performed operations on
many individuals suffering from constitutional syphilis, and he never noticed,
even in a single instance, anything particular in the aspect, progress, or dura-
tion of the wounds.

It will, perhaps, be alleged, that experiments have been instituted, which
seem to point to the possibility of the transmission of syphilis by the blood of
diseased subjects. Thus, M. Waller, after scarifying the thigh of a patient,
dressed the wounds with lint impregnated with syphilitic blood; the part healed,
but about three weeks afterwards pustules appeared on the thigh. The fact is
true, says M. Ricord ; but it is proper also to add, that at the same time a simi-
lar pustule was developed on the shoulder. This chancre had, doubtless, the
same origin as the others, and entirely invalidates the case. At Lyons, analo-
gous experiments yielded conflicting results. Finally, M. Lalagade, the head
surgeon of the Hospital of Albi, who never had been affected with syphilis,
'publicly inoculated in his own arm the blood of three soldiers manifestly suffer-
ing from this complaint; and although, on each occasion, two wide and deep
punctures were performed, the results were entirely negative.

As to those sad instances of vaccination published in Germany, in France,
and in Italy, M. Ricord does not deny their accuracy; they assuredly deserve
consideration, but cannot be received as conclusive in the question, until all their

528

Progress of the Medical Sciences. [Oct.

attendant circumstances have been minutely weighed, and the reciprocal opera-
tion of cause and effect has been carefully inquired into. M. Eicord declared
that he gave his full approbation to the conclusions of a paper, published in the
Gazette Hebdomadaire, by M. Jaccoud, on the distressing occurrences observed
during the course of the last year in the province of Acqui.

M. Jaccoud, after reminding his readers that at the end of the month of May,
1861, syphilis broke out, three weeks after vaccination, in forty-six infants at
Rivalta, proceeds to state that an inquest was held as to the. cause of the
calamity ; and that, despite the apparent clearness of the facts, the committee
appointed to investigate the matter declined to pronounce on the alleged con-
nection between syphilis and vaccination, and declared that, in order to form
their judgment, further inquiry was necessary. He continues thus : —

" These gentlemen were both prudent and wise. Before admitting that syphilis
in this instance was transmitted with the vaccine matter, many difficulties and
obscurities have to be cleared away; it would further be necessary to solve
several important questions, which at present it appears impossible to reply to.
For our own part, an attentive perusal of the documents of the case has led us to
the same conclusion as Dr. Albertetti, who exonerates from all blame the vac-
cinations in question. The events of Rivalta present to our view two conspi-
cuous, but wholly distinct facts — viz., the vaccination of the infants, and the
subsequent appearance of syphilis in certain of their number. It is granted that
these two orders of facts occurred in succession, but for the present we are not
prepared to go any further, and to argue, pos^ hoc ergo propter hoc; the coinci-
dence is obvious, not so the inference of causality. Whatever interpretation be
adopted as to these facts, they convey a useful caution, and illustrate in an elo-
quent manner the necessity of taking into account the manifold elements in the
setiological history of vaccinal syphilis, and the extreme reserve required of the
physician in cases of this description."

" This view," said M. Ricord, " is in such perfect harmony with mine, that I
have nothing to add to M. Jaccoud's remarks. Let us admit, and carefully
inquire into, these cases, and let us guard against any predetermined notions on
the subject ; but as to the interpretation offered, let it be received with an amount
of hesitation and doubt, increased by the obvious fact, that if ever the transmis-
sion of syphilis with vaccine-lymph is clearly demonstrated, vaccination must be
altogether discontinued, for, in the present state of science, we are in posses-
sion of no criterion which may permit the conscientious practitioner to assert
that the lymph he inoculates is perfectly free from admixture with blood tainted
by syphilis." — Ranking and Radcliffe's Half-Yearly Abstract, vol. xxxv., 1862.

20. Treatment of Agues by Cinchonice Disvlphas. — Mr. H. R. Oswald states
[Madras Quarterly jQurn. Med. Sci., Oct. 1861), that he has been prescribing
the cinchonise disulphus in the Shemooga Hospital since 1857, up to the pre-
sent date ; during this period 4,985 cases of fever, of all types, have been treated,
so that he has had numerous opportunities for testing its virtues, and his expe-
rience has led him to form a high opinion of its powers as an antiperiodic. In-
termittent fever, as seen there, though not often fatal, is in many cases very
severe ; the ague especially is prolonged, and enlargement of the spleen frequently
met with, even in children of the tenderest years ; showing the truly malarious
origin of the disease. " With this field for observation," says Dr. 0., " I may state
that I am inclined to place cinchonine almost on a par with quinine ; in some cases
it fails, but not often. Doctor Kirkpatrick observes, the dose required to check
an attack of ague is about the same as that of quinine, but I do not quite coin-
cide with this, as I have generally found a rather larger quantity necessary,

" I have not tried the combination of quinine and cinchoniee disulphas, as in
cases where the latter has failed I have at once had recourse to the former.

" Royle states that ' Dr. Pereira and others consider it equal in medicinal
activity to the quinaa disulphas.' Dr. Waring says, 'its action is similar to that
of quinine, but it is less energetic, and consequently requires to be given in
larger doses.' Many cases in which it has been given might be adduced, but,
as they would occupy valuable space, it may be sufficient perhaps to mention,
that since its first employment by me, no less than 4 lbs. 10 oz., have been ex-

1862.]

Me.dical Pathology and Therapeutics.

529

pended in addition to quinine and bark, showing the estimation in which it is held.
In fact it is now in daily and constant use, and is as regularly indented for as
any other drug.

" For some time past, however, I have observed that the administration of the
cinchoniae disulphas is attended with certain physiological effects, which will
probably prevent it from ever being substituted for quinine under all circum-
stances. Dr. Kirkpatrick has mentioned that nausea and vomiting attend the
use of large doses, such as 15, 20 and 30 grains. I have, however, found that
nausea sometimes attends even 5 grain doses, and this is frequently accompanied
by giddiness, dryness, and constriction of the fauces, and sometimes purging
with pain in the abdomen. I observed some of these symptoms in my own
person after a 10 grain dose taken to check an attack of fever, and the same
remark has been volunteered to me by natives who have taken it : they pass
off" in a few hours ; as long as they last, however, they are very disagreeable, as
I can testify from personal experience.

" After a time there is apparently a 'tolerance' of the remedy, and these un-
pleasant symptoms are not perceived ; in long-continued doses the effect is
similar to that produced by quinine.

" I think then with these disadvantages the remedy is never likely to supersede
quinine, except where economy is a consideration. When this is the case, I
have no doubt that the cinchonise disulphas may be substituted for quinine in
the treatment of simple uncomplicated intermittents with equal safety and
benefit."

21. On the Treatment of Pneumonia : with the Results of One Hundred and
Five carefully recorded Cases. — At the late meeting of the British Medical
Association in London Dr. J. Hughes Bennett, of Edinburgh, read an inter-
esting paper under the above title.

By pneumonia, or inflammation of the lung, the author stated he understood
a disorder essentially composed of an exudation from the blood among the
elementary textures and into the air-vesicles of that organ, which gives rise to
those well-known physical signs and functional symptoms with which all are
familiar. This, like most other inflammations, when acute, was formerly treated
by so-called antiphlogistics — that is to say, bloodletting, purgatives, antimonials,
low diet, and other methods of lowering the strength of the patient. It was
about eighteen years ago, in consequence of investigating the pathology of in-
flammation, that Dr. Bennett began to doubt the propriety of such a treatment,
and this for the following reasons : —

In the first place, the cause of the inflammation is an irritation of the textures,
of the ultimate molecules, of the part; in consequence of which their vital power
of selection is destroyed and that of their attraction is increased. The removal
of blood by venesection cannot alter this state of matters, neither can other
lowering remedies. If the inflammation be superficial and limited, local bleeding
may diminish the congestion, as in conjunctivitis ; but if exudation has occurred,
it cannot remove that.

In the second place, an exudation or true inflammation having occurred, it
can only be absorbed by undergoing cell-transformation. Now this demands
vital force or strength, and is arrested by weakness. Inflammations in healthy
men rapidly go through their natural progress. In weak persons they are de-
layed or arrested: hence their fatality.

In the third place, the strong pulse, fever, and increased flow of blood in the
neighbourhood of inflamed parts, ha ve been wrongly interpreted by practitioners.
They are the results, and not the causes, of inflammation ; and show that the
economy is actively at work repairing the injury. So far, therefore, from being
interfered with and interrupted, they should' be supported by nutrients.

It follows, fourthly, that if these views be correct, the true treatment of
inflammation should be directed towards bringing the disease to a favourable
conclusion by supporting, rather than by diminishing, the vital strength of the
economy; and this, not by over-stimulation, as was done by Dr. Todd, but simply
by attending to all those circumstances which restore the nutritive processes to
a healthy condition.

No. LXXXYIIL— Oct. 1862. 34

530

Progress of the Medical Sciences.

[Oct.

Having been guided by these views in Ms practice for the last fourteen years,
and having seen that they have been gradually adopted by the profession. Dr.
Bennett offered the most convincing proof of their correctness from an analysis
of 105 cases of pneumonia publicly treated in his clinical wards in the Eoyal
Infirmary of Edinburgh, and carefully recorded by his various clinical clerks.
In all these cases the treatment was directed to the support of the economy,
never to weaken it by antiphlogistics. At the same time, if dyspnoea be urgent,
cupping or a small bleeding (from four to eight ounces) may be practised as a
palliative, more especially in bronchial or cardiac complication — although in
none of these cases was such bleeding ever found necessary by him. During the
febrile excitement mild salines are administered. On the fourth or fifth days,
when the fever abates, good beef-tea and nutrients are administered ; and on the
pulse becoming soft or weak, from four to eight ounces of wine daily. As the
period of crisis approaches, slight diuretics are given to favour the excretory
process. The results are —

Single uncomplicated cases . . 58
Double " " . . 19

Complicated cases . . . .17
Unsatisfactory cases (as to duration) 8
Deaths . . . . . .3

105

Eatio of deaths, 1 in 35 cases.
Average residence in the hospital of 77 uncomplicated cases of pneumonia
(single and double), 22^ days.

It has been supposed that in consequence of this comparatively small number
of cases occurring in so long a period as fourteen years the disease is rare in
Edinburgh. It should therefore be explained that the clinical professors are en
duty alternately, and that he (Dr. Bennett) had never acted as physician to the
Infirmary more than one-half of the year, and in most cases only one-third of
the year. It has also been imagined that pneumonia in Edinburgh is unusually
slight and trivial, or that the disease in these cases was not extensive. But it
is not so. Many cases, and especially the double ones, were very severe, with
great dj^spnoea and very urgent symptoms. Dr. Bennett had frequently pointed
out the existence in these cases of the hard and strong pulse in vigorous young
men, in whom, however, the most rapid recoveries were invariably observed. It
should also be noted that these cases were in no way selected, but included not
a few which were admitted in extremis by the resident clerk, and never seen by
the physician ; nor such as were partly treated by other physicians in the hos-
pital, and for which treatment Dr. Bennett was not responsible.

From these facts Dr. Bennett concluded : —

1. That simple pneumonia, if treated so as to support, instead of lower, the
nutritive processes, so far from being a fatal disease, almost invariably recovers.

2. That the cause of mortality in these cases is exhaustion, either before they
come under medical supervision, or, as formerly practised, by a lowering treat-
ment. Bleedings or other remedies that do not exhaust must be regarded as
palliative rather than curative, and their influence has yet to be determined with
exactitude.

3. That the same rule applies to all inflammations, the amount of danger being
in direct ratio to the weakness of the system ; the existence of complications in
other viscera, or blood poisoning.

Dr. Bennett was of opinion that these important results were not the effect of
chance; of empirical experiment; of a change in the nature of inflammation, or
of the force of the pulse in man and animals ; of an alteration of diet or of drink,
or of nervous susceptibility; nor of a change of type in disease: all of which
have been supposed by some explanatory of facts which can no longer be denied.
The more he considered this subject, the more was he convinced that it could
only be -justly attributed to the advance of medical science, and that it was a
source of infinite satisfaction for medical men so to consider it. He thought it
strange that some minds would rather ascribe so manifest an improvement in

Average duration 13^ davs.

20 "
15f "

1862.]

Medical Pathology and Therapeutics.

531

the treatment of disease to hypothetical revolntions in nature which had no
proof in their support, than to the increase of knowledge amongst the profession
which was obvious to all. It seemed to him that if any one demanded in what
way our advance in physiology and pathology had benefited the treatment of
disease, no better proof of it could be found than in the diminished mortality
that evervwhere now accompanied attacks of acute inflammation. — Lancet,
August 16, 1862.

22. The Therapeutics of Delirium Tremens.— The Madras Quarterly Journal
of 3Ied. Science for October, 1861. contains some interesting observations on this
subject by J. L. Raxkixg. Esq., Surgeon Major. H. M.'s 105th Regiment L. I.

'•'Within the last few weeks," he remarks, -'the payment of the •bounty' has
afforded the men the means of indulging their propensities for drink to an extent
which probably never fell to their lot before. Some thousands of rupees were put
into circulation, and the consequence was that 81 cases of ebriositas (drunken-
ness in its most profound form), and 14 cases of delirium tremens passed through
the hospital.

" The experience thus afforded us has led to our forming an opinion as to the
therapeutics of delirium tremens which we may express in the following propo-
sitions : —

" 1st. That in the very large 'majority of cases alcohol may not only be safely
but advantageously dispensed ivith.

"2d. That it, or other accustomed stimulus, caniiot he entirely laid aside in
old soldiers ; men who have drank hard all their lives, and who have experienced
prior attacks of the disease.

"3d. That opium is unnecessary in all cases, and positively injurious in
many.

" Or to express the propositions differently: —

"1st. The young soldier, ivhose elimincttive powers are unimpaired, can be
treated with safety and advantage without a drop of alcohol or a grain of
opium.

"2d. The oM soldier zt'/f^ organic viscercd (i?.'secise, requires no opium: but
does require some of his ' accustomed stimulus' combined with eliminants and
nutrients.

"3d. T}i?it opium is unnecessary in all cases; that it often fails to induce
sleep, which succeeds to its withdrawal.

"4th. That if pushed to its full extent, it may and sometimes does induce a
sleep passing into coma and death."

The result of the treatment of 14 cases upon the plan indicated by Mr. R.
are very encouragiug: —

" Of these 14 cases, three presented all the symptoms characteristic of the
fully developed disease, or of the third stage. In two there were unquestionable
evidences of organic disease of the kidneys ; a complication of a most formidable
nature, and one materially influencing the result. One, treated entirely luithout
opium and cdcohoh died : the other, wlio had a moderate aUowance of alcohol,
recovered. The third, a young soldier but with a very severe attack of the dis-
ease, recovered without, as before said, a grain of opium or a drop of spirit.

"'The mortality in relation to these 14 cases, then, stands as follows: One in
14 as relates to the whok group without reference to the stages of the disease.

" Or, all in the first and second stages of the disease recovered, while of those
advanced to the third stage one in three died.

" Without appearing to contend too warmly for the treatment without opium
and alcohol, we may advantageously inquire, would the case lost, taking into
consideration the condition of the kidneys, and we may add also of the liver,
which was far advanced in fatty degeneration — would that case have benefited
by the exhibition of opium and alcohol, one or both? Knowing as we do. that
opium is very ill borne in all cases of organic renal disease, that a dose of that
drug which may safely be given to a healthy individual, may prove a poisonous
dose to one whose kidneys are organically diseased, our answer must be, we
think, in the negative. Alcohol, in a similar case occurring to us, we should
with the experience since afforded us, certainly give in moderate doses, to sus-

532

Progress of the Medical Sciences,

[Oct.

tain tlie vital powers while the blood was being rid of its urea ; for in the case
alluded to, we have no doubt that death resulted from ursemic poisoning ; the
condition of the urine during life, and examination of the kidneys after death,
proved that they were spoiled for all the purposes of elimination.

" We would also remark that this case is the only one which has occurred in
our practice, which in the least degree favours the views of those who consider
that the disease is often caused by the withdrawal of the accustomed stimulus.

" The patient was a known sot. On admission his case did not appear a very
severe one, and it was not till the third day after admission that serious symp-
toms arose. Would a pretty liberal allowance of brandy from the commence-
ment have saved him ?

" It remains for us to give the promised instances of the injurious effects of
large and repeated doses of opium.

" In two cases in which many nights had been passed without sleep, cases
which we had treated on the elirainant and nutritive system entirely, it appeared
desirable to force sleep. In each case ^iss of the liq. opii sedativus was pre-
scribed at 8 P. M., and 3;ss directed to be repeated every two hours till the
patient slept. In both instances we were summoned after midnight, the patients
being in a state of alarming sinking or collapse, both under the impression that
they were dying. In both instances the opiate was withdrawn, and camphor
and brandy given. They rallied slowly, and both slept the following night after
the exhibition of a glass of hot ' brandy and water.' We could not attribute
the condition of collapse in these cases to anything than the liq. opii — the
patients themselves attributed their feelings to the opiate, and both rallied
under stimulants after the withdrawal of the opiate. The ill effects of the
opiate and the beneficial effects of the brandy were to our mind most apparent.
These were the only two cases in which full doses of opium ' fearlessly repeated"
were tried — no sleep followed, although in each case giiss of the drug had been
taken, and our jBrm impression and belief is, that, if we had continued it till the
patients slept, they would have slept the sleep of death.

"We are aware that we have advanced nothing new in this paper — all has been
said before, much better than we have written it.

" We are, however, so strongly impressed with the weight of the moral and,
we may add, economic grounds upon which the system advocated is based, that
we have considered it our duty to show the extent to which we have been able
to apply it during a period of an almost unprecedented excess.

" The economic value of the system as applied to this regiment we will eluci-
date in our concluding remarks.

" Since the arrival of the regiment at this station in April, 1858, up to the
date of our assuming charge, we find 171 cases of 'ebrietas' and ' delirium tre-
mens,' with a total expenditure of brandy {in such cases only) of bottles 96 and
measures 5, or allowing 24 ounces to each bottle of 14 imperial gallons.

"In our practice between 81 cases of ebriositas and 14 of delirium tremens —
total 95 — the expenditure has only been bottles 3 and measures b^.

" On the old system it would have equalled (taking the average of 171 cases
above given) some 53 bottles, represented in value, at the commissariat rates
of Rs. 18-4-0 per dozen, by Rs. 84.

" We hope, or we should rather write expect, to have further opportunities
afforded us of testing the merits of the system of treatment without alcohol
and opium. We do not think, however, that further experience will materially
modify the opinion we have already expressed.

" The systematic examination of the urine for evidences of organic renal disease
should never be omitted. Prognosis hinges mainly upon the existence or non-
existence of organic changes in the kidneys and liver, and we have a strong-
suspicion that the large majority of cases which terminate fatally will be found
to be associated with such pathological conditions, as forbid the hope of elimina-
tion of the poison of alcohol, at the same time that they offer the further com-
plication of urseraic poisoning."

23. Delirium Tremens — Large Doses of Tincture of Digitalis — Cure. — M.
F. Manifold relates [Med. Times and Gaz., Aug. 23, 1862) the case of a soldier,

1862.] Medical Pathology and Therapeutics.

533

aged 27, stout and muscular, brought to the hospital January 4, 1861, in a state
of great nervous depression and mental anxiety after a series of debauches dur-
ing Christmas week, ending in a convulsive fit, in which condition he was con-
veyed to the hospital from his barrack-room. He was immediately placed in
bed, in a ward by himself, in charge of an European orderly, and directed the
following draught — U. Garb, ammonise gr. v, mist, camphorge .^j, liquor opii
sed. iT^xx; fiat haustus s.s. et rep. tertiis horis. He was also ordered beef-tea,
and the head to be kept cool.

January 5. Has had no sleep. Tremens well marked. Endeavours to get
out of bed, and is with difficulty prevented from doing so. To have a calomel
purge,, followed by a cathartic draught combined with antimony, and one grain
of morphia at bed-time; also, beef-tea and beer.

Third day. Yery restless and delirious, talks wildly and incoherently, and has
had no sleep since his admission into the hospital. Morphia combined with
antimony repeated every third hour without producing the desired effect.

Fourth day. Much worse in every respect ; wandering and delirious, although
conscious when spoken to sharply. To have tinct. digitalis ^iij immediately,
and the following mixture — li. Tinct. digitalis .^j, tinct. lavand. co. ^ss, mist,
camphorge ad ^viij ; fiat haustus. Dose omni secund. hora.

Fifth day. Much better this morning, after a refreshing sleep. To continue
the mixture.

Seventh day. Convalescent. From this date he improved gradually, although
weak, and was discharged to duty on January 18, 1861.

Remarks. — The beneficial effects of the digitalis were well marked in this
case, the first dose acting as a powerful sedative, allaying irritation, and produc-
ing sleep. I would have no hesitation, in a similar case to the above,, giving
half ounce doses of the tincture, to be repeated, if requisite, every second or
third hour ; but this will seldom be found necessary.

In a case in which I was lately consulted by Dr. Barn, Eoyal Artillery, in
which there was well-marked insomnolence, jactitation, and delirium, and where
both morphia and hyoscyamus have been administered in vain in large doses
the second dose of tincture of digitalis acted like a charm.

24. Action of Quinia upon Phthisis. — With the view of testing, so far as
practicable, the general therapeutical value of quinia in the treatment of con-
sumption. Dr. Richard P. Cotton prescribed it for twenty-five patients, in
various stages of that disease; avoiding, as in all his previous experiments, any
selection of cases, and excluding only those unfitted by the existence either of
acute symptoms or special complications. The dose consisted, according to
circumstances, of one or two grains two or three times a-day ; and was continued
for periods varying from three to ten weeks. Notes were regularly taken by
Dr. Harington. resident clinical assistant.

■ Ten of the patients were in the first, six in the second, and nine in the third
stage of phthisis. Sixteen were males, and nine females. Their ages varied
from twenty to fifty years.

During the administration of the quinia seven improved greatly, five im-
proved slightly, and thirteen either did not improve at all or became worse. Of
the twelve improved cases, seven were in the first stage, two in the second, and
three in the third stage ; and, of the thirteen cases in which the quinine seemed
to be inoperative, three were in the first stage, and ten were the subjects of
more or less advanced tubercular softening. Thus it would appear that what-
ever good may have resulted from the quinine, it was the most decided in the
early stage of the disease.

In fourteen of the cases cod-liver oil was taken during at least a portion of
the time. There was an increase of weight in ten out of the twenty-five patients ;
such increase occurring in five who had taken the oil, and in five who had not
taken it, but being most marked in the former.

In four cases the quinia appeared to disagree, producing dyspepsia and loss
of appetite. In six instances patients who had made little, if any, progress
under the quinia by itself, were more or less benefited when steel was added to
it. Two of these cases were remarkably good illustrations of the combined

534

Progress of the Medical Sciences.

[Oct.

influence of qiiinia and iron ; one was in an early and the otlier in an advanced
condition of disease, but both left the hospital with every local and general
symptom in abeyance, and their health fairly good, after taking for several
weeks two grains of quinia twice a-day, and a tablespoonful of steel wine im-
mediately after dinner.

From these facts, compared with previous observations on other remedies,
the following are the conclusions at which I have arrived : —

1. That although quinia may be well adapted to certain cases in which there
is an evident cachexia, it is greatly inferior, as a general remedy in phthisis, to
some other tonics, whilst in a few instances it is unsuited to the disease.

2. That the combination of quinia and iron is sometimes very beneficial. — ■
Med. Times and Gaz., Aug. 30,' 1862.

25. Treatment of Acute Dysentery -hy the Nitrate of Silver. — Dr. Duclos
considers that dysentery always commences at the lowest part of the large
intestine, and if such be the case, then he argues that the local medication of
this part must arrest the disease and prevent its extension, or at least must
modify its virulence even in the worst cases. Local treatment being, therefore,
admissible in this disease, the beneficial effects will be in proportion to its em-
ployment at the earliest period. Dr. Duclos was induced to employ nitrate of
silver as the remedial agent, from observing its well-known efficacy' in purulent
ophthalmia, aphthous eruptions in the mouth, and other such affections, and also
from witnessing the practice of M. Trousseau, who employs this salt with great
success, both by the mouth and in injections, in cases of simple enteritis in very
young children. M. Duclos treats dysentery in the following manner : a slight
laxative is first administered, such as a small dose of calomel or seidlitz powder,
in order to unload the intestine of fecal matter, and then a simple mucilaginous
enema is thrown into the rectum. When the laxative and the injection are both
evacuated, an enema is administered, consisting of twenty-five centigrammes of
nitrate of silver (a centigramme is .1543 of a Troy grain) in one hundred and
fifty grammes of water (a gramme is about fifteen grains), together with some
laudanum if necessary, but the latter is only added if it is quite impossible to
retain the enema for a few seconds. The enema is kept in the rectum for from
four to ten minutes and then allowed to return, and as it has been administered
immediately after an evacuation, it is certain that the silver salt has been in
direct contact all the time with the diseased surface. An enema is thus given
night and morning, and M. Duclos has even given three in twenty-four hours ;
and this treatment is continued for several days, with the double view of avoid-
ing constipation, which is the habitual attendant of true dysentery, and of giving
the enema immediately after a dysenteric evacuation has cleansed the last por-
tion of the intestine. The results of this treatment are, that in general the
stools are rapidly modified both in frequency and composition. Most frequently,
from the period of the fourth or fifth enema, they become less frequent, and also
less bloody and slimy; the tenesmus also diminishes with great rapidity, and the
pain produced on pressure of the left side is less acute. No bad results were
observed to follow this treatment, but sometimes an excessive irritability of the
anus or the rectum rendered it necessary to change the form of administering
the injection. The dose of the nitrate of silver was then reduced, or a greater
or less quantity of laudanum was added to secure its tolerance by the intestine.
Dr. Duclos has employed the nitrate of silver in the manner described in a great
number of cases of dysentery, and often with great success, and he records five
cases at length. His views have been confirmed by the observations of other
practitioners, and they may be summed up as follows : 1. The nitrate of silver,
administered at the commencement of acute dysentery, in appropriate doses,
constitutes a remedial agent which has produced very excellent results in Dr.
Duclos's hands ; 2. Its action has been equally efficacious, whatever may have
been the age of the patient, and in all the forms of dysentery ; and 3. In certain
cases, when administered quite at the beginning and always in injection, it has
seemed to exert, at the end of a few days, an almost abortive action upon the
disease. — B. and F. Med.-Chir. Rev., July, 1862, from Bull. G6n. de Th&rap,,
August 15, 1861.

1862.] Medical Pathology and Therapeutics. 535

26. Treatment of Acute Eheumatism, considered with regard to the liability
to Affections of the Heart under different Remedies. — Dr. Dickson read before
the Royal Medical and Chirurgical Society (June 10) a paper on this subject,
based upon a tabular condensation of the cases of acute rheumatism which were
admitted into St. George's Hospital during the five years ending on December
31, 1861, and in whom the heart was, on admission, unaffected by the disease.
The method of treatment adopted in any particular case depended very much
upon the chance of the patient coming under one physician rather than another ;
and a comparison of the results would, to a certain extent, be a guide to the
value of the means used. The cases, therefore, were classified according to the
treatment made use of. As the main object of the investigation was to ascer-
tain the effect of remedies in preventing cardiac mischief, the arrangement was
not altered by measures adopted in consequence of its occurrence. The tables
were fourteen in number. The first gave the results of eight cases in which
venesection was early resorted to, other medicines being at the same time used.
In three of the cases endocarditis or pericarditis was clearly recognized. In
one there was incomplete evidence of cardiac derangement. The heart, there-
fore, was absolutely uninjured in only half the number. The patients remained
in the Hospital for an average period of forty-one days. Bouillaud, who is the
great advocate of bleeding in this, disorder, and trusted to it almost exclusively,
expresses his opinion that such complications are the rule, and not the excep-
tion. The second table gives the result of six cases treated solely with repeated
doses of calomel and opium. In two subsequent classes were seen the effects of
the same medicines aided by saline draughts, with and without nitre. The pro-
gress of the disease under each plan appeared to be much the same. The total
of twenty-four cases presented six of inflammation of the heart or its membranes,
of which two proved speedily fatal. The average number of days in Hospital
under mercurial treatment was thirty-seven. The action of some reputed specific
remedies was then considered. With regard to opium, reference was made to
some tables published by Dr. Sibson in the Association Mediccd Journal.
Twenty-one cases are here recorded, in which, when the treatment was com-
menced, the sounds of the heart were natural. Opium was given in frequent
doses, sometimes as much as a grain an hour, besides other remedies supposed
to have an effect in rheumatism. No less than fourteen of these cases, or ex-
actly two-thirds, manifested while under treatment symptoms of valvular or
pericardial inflammation. The cases, seven in number, treated with nitre alone,
gave only one of cardiac complication. The average duration of the treatment
was reduced to twenty-seven days. Further evidence in favour of nitre was
deduced by comparing the result of cases treated with saline remedies alone,
and those which had salines with nitre in addition. A table contributed by Dr.
Basham to the Transactions of the Society was quoted. Of sixty-seven cases
of acute rheumatism treated with large doses of nitre, the heart being in each
case unaffected at the commencement of the plan, six only had symptoms of
inflammation of that organ. In considering the treatment of saline remedies,
the use of the term was limited in an arbitrary manner. It was assumed that
the salts which potass and soda form with the vegetable acids undergo such
changes in the system as to become equivalent, or nearly so, to the same quan-
tity of alkali in combination with carbonic acid. Whether a certain quantity of
potass is given as citrate, tartrate, acetate, or carbonate, the effect upon the
urine and upon the system generally was held to be much the same. The
arrangement was made accordingly. Those patients treated with an aggregate
of such salts not reaching three drachms a day were considered as under saline
treatment ; those taking as much as three but less than four drachms, as under
partial alkaline treatment ; those taking from half an ounce to an ounce and a
half, as under full alkaline treatment. Sixty-two cases appear to have been
subjected to saline treatment, alone or with other remedies. These afforded a
proportion of heart affection of 1 in 3.6. The conclusion was that salines in
such quantities had but little influence upon the course of the disorder; when
used in conjunction with more potent remedies, the result always corresponded
with the observed effect of the additional medicines when used independently.
With the increased doses, which the author distinguished as partial alkaline

536

Progress or the Medical Sciences.

[Oct.

treatment, no diminution of the heart symptoms was observed, although the
disorder terminated in rather a shorter time. The full alkaline treatment was
exemplified by two tables. It consisted in the administration of the salts which
potass and soda form with carbonic and the vegetable acids, in quantities vary-
ing from half an ounce to an ounce and a half daily. Half a drachm of the
acetate, with twice as much of the bicarbonate of potass, dissolved in the haustus
ammonige acetatis of the Hospital Pharmacopoeia, furnished an ordinary form of
prescription. This was given every four or six hours, and sometimes'^ made to
effervesce by the addition of a little citric acid. Salts of soda were sometimes
resorted to. The total of forty-eight patients thus treated passed through the
dangers of the disease, with only a single instance of any cardiac affection. In
the exceptional case the murmur came on within twenty-four hours of the com-
mencement of the treatment, and did not prove permanent. The average num-
ber of days in hospital, when this treatment was applied simply, was twenty-five,
the smallest of all ; when other medicines, as colchicum, were used in addition,
five days were added to the average period. Dr. Garrod's published cases, in
which laicarbonate of potass was used alone, were quoted as rather less success-
ful than those at St. George's, in which neutral salts were given in addition.
Twenty-four of Dr. Garrod's cases afforded three of inflammation of the heart or
its membranes. It was concluded that the carbonates of potass and soda, and
those of their other salts which in the body are capable of being converted into
the carbonates, exert an especial curative power in rheumatic fever, and, if given
in time, will completely protect the heart from the dangers by which it is sur-
rounded. Taking the proportion of heart affection under the alkaline system,
one in forty-eight, and, with this as a standard, reviewing the other plans of
treatment, the result was striking. One hundred and thirteen cases where other
remedies were used gave thirty-five instances of cardiac mischief, or a propor-
tion of 1 in 3,2. Nitre, next to the alkalies, was the most successful. The
general symptoms were shortened under its use. and the frequency of cardiac
inflammation was reduced to 1 in 10. Kegarding the other remedies which have
been credited with the cure of acute rheumatism, it simply became a question
which were useless and which injurious. Mercury allowed a proportion of car-
diac inflammation of 1 case in 4. Saline treatment gave a worse result. With
bleeding one-half of the cases became thus complicated. Under opium the mis-
chievous influence of the disorder attained its maximum. Two-thirds of the
cases so treated had the symptoms of endocarditis or pericarditis. With the
exceptions stated, it was maintained that the more active the remedies the more
untoward, generally speaking, is the progress of the disease. It was shown
that the use of colchicum retarded the recovery of the patient. The practical
deduction was, that acute rheumatism is best treated by giving at short intervals
a solution of nitrate, acetate, and bicarbonate of potass in such doses that ten
or twelve drachms of the two latter salts together are taken in the twenty-four
hours. Half a drachm of the acetate, with a drachm or a drachm and a-half of
the bicarbonate, and ten grains of nitre, would answer the purpose. A brief
review of the history of the alkaline treatment of rheumatism concluded the
paper. — Med. Times and Gaz., June 21, 1862.

27. Veratria in Rheumatic Fever. — In a clinical lecture recently delivered
by M. BoucHUT at the Hopital Ste. Eugenie, the employment of veratria in the
treatment of rheumatic fever in children is strongly advocated. M. Bouchut,
whose opportunities for testing any novel method of medication are so extensive,
comes forward with thirty cases of acute rheumatism, in which veratria has
proved suSicient for the cure of the malady in from three to twelve days, the
amelioration setting in on the second or third day of its administration. One
of the most remarkable effects of the action of veratria in rheumatic fever is
the rapid fall of the pulse; whatever its frequency, the diminution under the
use of this drug is most marked, the pulse falling to sixty or even fifty, becoming
almost thready and imperceptible, without causing to the patient any feeling of
malaise.' This abatement of the circulation M. Bouchut considers as the signal
for the diminution of the doses. With regard to the effect of veratria on heart
complications, this is probably indirect and due to the annihilation of the rheu-

1862.]

Surgery.

m%tic poison. Besides its influence on the pulse, this medicine may, if given in
too large quantities, irritate the mucous membranes, and produce vomiting',
diarrhoea, and colic. The doses should therefore be small, and the ordinary
formula recommended is, veratria and extract of opium one grain each, to be
divided into ten pills, of which two pills are to be given the first day, three the
second, four the third, five the fourth, and so on, increasing one pill each day
until the condition of the pulse or the irritation of the mucous membrane com-
pels a diminution. The difference of price in hospital practice between the use
of vei-atria and that of sulphate of quinia, is of course one point of comparison
in which the advantage remains very decidedly with the former ; add to which,
in a therapeutical aspect, veratria is perfectly innocent of those charges of
exciting rheumatic determination to the membranes of the brain which in some
measure appear to have been justly adduced against quinia since the employ-
ment of large doses of this drug has come into fashion.

SURGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIVE

SURGERY.

28. Iliac Aneurism remedied hy opening the Sac, and tying the Common
Iliac, and the Internal Iliac Arteries. — Professor James Syme, of Edinburgh,
communicated a case of this to the Royal Medical and Chirurgical Society
(May 27, 1862). He reminded the society that ten years ago he had endeavoured
to show reason for regarding the preference which had been given to the Hun-
terian operation for aneurism as too exclusive, since the circumstances which
rendered it so advantageous in cases where the popliteal artery was affected
might be so different in other situations as to reverse the grounds of choice— as
in axillary aneurism, where the vessel is easily reached at the seat of rupture,
and with great difficulty, as well as danger, tied a,bove the clavicle. In reply to
the doctrine usually taught, that the artery is not in a condition suitable for the
ligature so far as the aneurismal sac extends, it was remarked that the size of
the tumour does not depend upon the state of the vessel, and therefore cannot
be taken as any measure of the extent to which its coats are impaired ; while
the formation of a sac, so far from proving injurious to the artery, must rather
tend to strengthen and support it by consolidating the textures in its neighbour-
hood. Trusting to this view of the matter, the author had operated with success
in various cases, and now desired to relate one of recent occurrence, which
seemed strongly corroborative of the opinion he had expressed. R. L., a sea-
man, aged 31, towards the end of November last received a blow on his left
groin, which caused a painful swelling that was treated as glandular; and about
a month afterwards strained himself on the same side in leaping from a ship that
was about to sink, with the effect of causing the formation of another tumour
some inches higher up than the former one. On this account he repaired to the
Cumberland Infirmary, at Carlisle, and was then found to suffer from an iliac
aneurism. After remaining a week in the hospital, he went home until the end
of February, when he was admitted into the hospital of Dumfries. Operative
interference having been there declined, the patient again went home and betook
himself to intemperate habits, with the effect of injuring his health and greatly
increasing the tumour. On April 18 he was admitted into the Royal Infirmary
of Edinburgh, when the aneurism was found to extend from below Poupart's
ligament considerably higher up than the umbilicus, and from two inches beyond
the middle line of the abdomen towards the right side, completely across the left
iliac region, so as to overlap the crest of the ilium. There was a strong pulsation
throughout the whole extent of the tumour, great pain in the course of the crural
nerve, and considerable oedema of the thigh. On the 20th, chloroform having
been administered, the cavity was examined by introducing first one finger, then
another, and finally the whole hand, without any trace of the artery being de-
tected, whence it was concluded to be out of its usual situation. A screw clamp

538

Progress of the Medical Sciences.

[Oct.

provided by Professor Lister, of Glasgow, was then employed to effect compres-
sion of the aorta ; and this having been ascertained to be complete, a free incisfon
was made through all the textures concerned, so as to lay the sac fully open,
and allow six pounds of blood and clots to be scooped out. It then appeared
that the arterial orifice was in the roof of the aneurism, from the vessel having
been raised in this direction by the blood effused under it ; and this orifice being
brought distinctly into view by dissection of the sac, was tied on both sides of
the vessel. But as blood still issued, though not with the same force as before
the ligatures were applied, it was concluded that the internal iliac originated
from the portion of artery comprehended between them ; and this vessel also
having been exposed, was tied by a thread passed round it. The wound was
then dressed superficially, and everything went on favourably. On the nine-
teenth day the ligature separated, and the cavity gradually contracted. Some
observations were then made — 1. On the importance of ascertaining that the
aorta could be effectually compressed so as to prevent hemorrhage from its
primary branches. 2. On tM sac not maintaining a profuse and protracted
suppuration like the investment of a chronic abscess, but readily contracting so
soon as the distending force ceased to act. 3. On the impossibility of affording
relief in the case related by any other means than the one employed, and the
danger which would have attended ligature of the common iliac at an earlier
period from the aperture being so near the bifurcation. In conclusion, the
author expressed his hope that the cases of carotid, axillary, gluteal, and iliac
aneurisms which had come under his observation would induce teachers of sur-
gery to reconsider the propriety of representing the Hunterian operation so
exclusively the rule of practice as it had hitherto been regarded.

Mr. S. said there were three points to which he wished especially to direct
attention : First. That there was no reason to conclude that the artery in the
sac of an aneurism was unsound beyond the point of rupture, and. if sound, it
was better to tie near that point. Secondly. That the artery, if unsound at the
seat of the aneurism, is just as likely to be unsound at parts at a distance, where,
jaccording to the Hunterian method, it is usual to tie it. In the case of axillary
aneurism which he had previously brought before the society, the patient got
quite well and to his work, but afterwards died of aneurism of the aorta. In
' this case the whole arterial system was diseased. Thirdly. If the arteries are

unsound, it is better to tie near the ruptured part. In ligaturing arteries in
stumps after amputation, he had found the arteries so diseased that they grated
under the ligature, and yet the case did well. In some cases, as in popliteal
aneurism, it was impossible to tie the artery at the ruptured part. He felt
confident that these principles were correct ; but one case, under Sir Astley
Cooper's care, of ligature of the abdominal aorta, made him feel anxious. The
patient was a man, aged 38. The aneurism followed a blow. It gradually
increased in size, and pressure applied to it caused sloughing, followed by hemor-
rhage. Sir Astley Cooper endeavoured, by making an opening, to compress the
artery, but on introducing his hand felt nothing but a confused mass of clots.
He therefore enlarged the wound, and ligatured the aorta above the bifurcation.
In the dissection of this case it was stated that the track of the artery was not
in the aneurism. He (Mr, Syme), with the greatest respect for the opinion of
Sir Astley Cooper, felt inclined to believe that he had been mistaken, rather
than that there was an exception to the universal rule. — Med. Times and Gaz.,
June 14, 1862.

29. Ligature of the Common Iliac Artery. — Mr. E. R. Bickersteth relates
{Edinburgh Medical Journal, July, 1862) the following interesting case of
this : —

"T. A., get. 39, a strong, muscular man, by trade a boiler-maker, was admitted
into the Royal Infirmary under my care on the 24:th of February last. He is of
sanguine temperament, of steady habits, but deaf, as nearly ail boiler-makers are.
Till within a few days of his admission he had worked at his trade without much
inconvenience. He stated that three or four months before he had felt some
uneasiness in the right side of the abdomen and in the front of the right thigh,
but that until aboat six weeks ago there was no perceptible enlargement to be

1862.]

Surgery.

539

discovered. He then found a tumour a little above the right groin, which con-
tinued to increase up to the time of his admission. He could not recall any
accident or other cause for its formation.

" On admission, a pulsating tumour was felt occupying the entire iliac fossa,
and extending in the direction of the artery from an inch and a half below Pou-
part's ligament to within two inches of the umbilicus. When the patient was
recumbent the tumour did not cause any perceptible fulness, except in the groin,
where it was raised about an inch above the natural contour ; but, on feeling
through the abdominal parietes, which were very strong and muscular, the
tumour was distinctly felt occupying the whole of the iliac fossa, extending late-
rally from the ilium to beyond the linea alba. Superiorly, owing to the thick-
ness of the parietes, it was impossible to define its exact limits ; but when the
fingers were pressed deeply into the abdomen, two inches below and to the outer
side of the umbilicus, the rounded upper end of the tumour was felt expanding
with each pulsation, and gave the impression that the aneurismal sac extended
even higher than could be felt. Pressure upon the tumour caused considerable
uneasiness, without perceptibly decreasing its volume ; but, from its position
and shape, and from the very distinct pulsation, there could be no doubt of its
being an aneurism of the external iliac artery.

"For a few days the man was kept quiet in bed, directions being given that
no one should examine or handle the tumour. It appeared, however, that the
examination on admission had disturbed the parts; for he soon began to suffer
acutely from pain down the thigh and leg, and also from pain in the tumour
itself, with griping and fiatulence over the abdomen generally. Opium and
emollient applications afforded partial or temporary relief; but the tumour
enlarged rapidly, and the abdominal pain became so severe that the patient
complained greatly, and got into a restless and feverish condition. It was evi-
dent that if any operation was to be undertaken, it must not be longer delayed.
From the high position of the tumour, I was convinced ligature of the external
iliac would be impracticable, and that the common iliac must be tied, if, indeed,
it even could be reached ; for I was not without grave suspicion lest, after
dividing the muscular parietes of the abdomen, I might find the sac of the aneu-
rism extending upwards so as to involve this artery also.

" The abdomen was much distended and hard from muscular contraction, de-
pending apparently on colicky pain, from which the man now almost constantly
suffered. A dose of castor oil with laudanum was ordered, to be followed the
next morning by a turpentine enema should the belly continue tense.

''March 4. The bowels having acted freely with the enema, the abdomen was
fortunately much softer and less swelled. Chloroform was administered. I made
a nearly vertical incision, five inches in length, midway between the anterior
spine of the ilium and the umbilicus. One inch of the incision was above the
level of the umbilicus, and the lower four inches passed in a slightly curved
.direction (the concavity being inwards) over the surface of the tumour. Having
divided the skin and fascia to this extent, I dissected through the muscles and
fascia transversalis at the lower end of the incision, and then introducing my
finger as a guide, I separated and protected the peritoneum, and with a blunt-
pointed curved bistoury cut through all the textures to the full extent of the
external wound. Laying aside the knife, and using only the fingers of both
hands, I then carefully detached the peritoneum from the upper edge of the iliac
fossa, and from the top of the aneurismal sac, which I could feel pulsating
strongly in the position in which I had hoped to find the common iliac artery.
Having continued the separation of the peritoneum from off the upper end of
the aneurism, and rather to its inner side, the forefinger of my right hand came
upon the artery, which appeared to be somewhat displaced, being pushed in-
wards, and rather lifted up by the tumour, upon which it rested. My colleague,
Mr. Long, greatly assisted me at this part of the operation, by pressing aside
the peritoneum and abdominal contents with one hand, while with the other he
introduced the narrow end of a long flat copper spatula to the bottom of the
wound and to the inner side of the artery, which was thus, with a little care and
a good light, brought into view. I had now no difficulty in exposing it; and
having opened the sheath with a narrow-bladed, sharp-pointed knife, I easily

540

Progress op the Medical Sciences.

[Oct.

insinuated from within outwards an aneurism needle armed witli a single silk
ligature round the vessel. This was tied as tightly as possible, and all pulsation
in the tumour at once ceased. No bleeding occurred during the operation, and
the wound, being carefully sponged, was therefore at once closed with metallic
sutures. The operation from beginning to end did not occupy more than twenty
minutes, I could not satisfy myself regarding the exact spot at which the artery
was tied. It appeared to be immediately beneath the umbilicus ; and, as I could
not feel any branch given off from it within half an inch of the spot at which I
passed the ligature, I suppose it must have been very near the middle of its
course, or perhaps rather nearer to the aorta. The right leg and foot were sur-
rounded with cotton wadding and a flannel bandage, and the patient removed
to bed. The subsequent progress is thus reported : —

"Next day, bth. Has passed a more comfortable night, and has had less pain
than for several weeks. The abdomen is flat and soft ; the tumour smaller and
harder, and free from pulsation. The epigastric artery is distinctly felt pulsating
vigorously upon the surface of the tumour. The foot and leg warm, and of a
healthy colour.

" Hh. All going on favourably. On removing the dressings from the wound, a
quantity of bloody fluid oozed from the incision by the side of the ligature, but
at all other parts the wound has healed by the first intention.

''8th. The escape of bloody serum from the wound continues. There is evi-
dently also a considerable extravasation of blood in the abdominal parietes on
both sides of the incision.

" 9th. Fluctuation and bulging of the abdominal walls over the crest of the
ilium is felt, and arises from retention of fluid in the cavity of the wound. An
incision through the skin in this situation gave vent to a large quantity of stink-
ing decomposed blood.

"lO^/i. Up to this date the patient has taken from one to two grains of opium
night and morning, with the object of keeping the bowels quiet, and they have
not acted. The man has continued quite comfortable and free from symptoms
of constitutional irritation. To day the abdomen is somewhat uneasy, the pain
arising from flatulence. Ordered an enema, and to omit the opium.

''lith. The bowels have acted freely, and the patient is more comfortable.
The wound looks well ; but there is still a very profuse discharge of fetid matter
from both incisions. Ordered six ounces of wine daily.

"From this time all went on very satisfactorily: the. discharge diminished
daily. On the 6th of April, the ligature came away, and a few days afterwards
the wound had entirely healed. The man was then allowed to leave his bed and
walk about. As there was some tendency to hernia, evidenced by bulging of the
abdominal walls at the lower end of the cicatrix, he was directed to wear a belt
to support the part. He remained in the house some time longer for the treat-
ment of a very tight and callous stri.cture of the urethra, anterior to the scrotum,
but was at length discharged cured on the 10th May. The aneurismal tumour
had then diminished to one-fourth of its original size, and still felt perfectly
solid and free from fluctuation.

"The most interesting pathological feature of this important case was the
peculiar position of the common iliac artery, which, instead of being covered
and enveloped by the sac of the aneurism, rested upon its inner and upper
surface. Had it not been for this (which analogy shows to be a most unusual
disposition of parts), I believe it would have been practically impossible, owing to
the high position of the aneurism, to have tied the artery without opening the
tumour. The possibility of being compelled to undertake this formidable mea-
sure, or otherwise abandon the case, had occurred to me before the operation.
Its feasibility and practical results in the case of subclavian and carotid aneu-
rism, otherwise beyond the reach of surgical art, had been demonstrated in the
admirable operations recorded by Professor Syme ; and I was prepared to seek
the artery within the tumour, if unable to reach it in the usual position. Pre-
vious experiment on the patient had proved that it was impossible to compress
the aorta -effectually while this was done; but still I hoped that the dissection
made in a vain endeavour to find the common iliac, might at least enable an
assistant to apply efficient compression on that vessel, or on the aorta, during

1862.]

Surgery.

541

the brief time that would be occupied in clearing out the clots and securing the
artery in the interior of the tumour."

30. Resection of the Elbow. — M. Bauchet exhibited to the Soci6t6 de Chi-
rurgie of Paris, a patient whose elbow he had resected in 1858. The result is
as satisfactory as possible. The patient enjoys excellent health, and uses his
forearm and hand as if his elbow had not been removed. All the motions of the
limb are easily performed, and its sensibility is everywhere unimpaired. Flexion
is very complete ; and extension is made voluntarily and forcibly, as may be
judged by grasping with the hand the forearm, and trying to resist the motion.
— Gazette Bebdomadaire, 4 July, 1862.

31. Complete Resection or Extirpation of the Astragalus. — Dr. Oscar Hey-
FELDER, of St. Petersburg, relates {Dublin Quarterly Journal of Medical
Science, Feb. 1862) two cases of extirpation of astragalus, which have occurred
to him since he published his book on resections of bones and articulations.

Case 1. Ivan Terasimof, 30 years old, coachman, received a semi-luxation of
the astragalus by a heavy butt falling upon the back of the extended and fixed
right foot. No wound of the skin, but a very considerable swelling of the ankle.
Eeceived into the hospital for workmen : the inflammation and swelling yielded
to an antiphlogistic treatment ; but the skin of the back of the foot where it was
over-extended by the luxated astragalus, became gangrenous, and the foot re-
mained in the position of extension, the ankle-joint being incapable of any move-
ment. After some weeks, not only this state remained, but a fistula had formed
Itself on the inside of the foot, corresponding to the anterior and exterior parts
of the astragalus, where a probe might be introduced into the softened osseous
tissue, and easily made to penetrate even to the skin at the exterior side of the
foot. The dislocation of the astragalus being an irreducible one, and the osseous
tissue being even carious, I proposed the extirpation of the dislocated bone ; the
more so as this operation, in sixty-three previously recorded cases, had given
very good success.

The 28th of September, 1860, I proceeded to the operation. A curved inci-
sion, the convexity towards the toes, divided only the skin, and permitted me to
separate the skin from the subjacent tissue, to separate the well conserved ex-
tensor tendons, and put them aside. The dislocated astragalus being pressed
into the tissue of the cuboid bone, and firmly retained by the posterior and infe-
rior ligaments, it could not be removed but with much difficulty, and by dividing
the tendons of the extensor digitorum longus. The astragalus being extirpated,
and the morbid parts of the cuboid being removed by help of a gouge, I joined
the wound with silver sutures, fixed the foot upon a splint, and laid it in a warm
water bath.

30th September. — The pains of the wound very tolerable in comparison with
what he had suffered before. Suppuration good; the whole state very satisfac-
tory. On the 8th October the sutures were removed, and almost the whole inci-
sion found closed by the first intention. The movement of the toes very easy,
and not at ail painful. In this, as in other cases, the secondary operation, in
comparison with primary ones, has proved preferable, by the slight degree of
reaction, and, in general, by the easiness with which this was supported.

When the permanent bath ceased to be agreeable to the patient (about the
14th day), the limb was put in a dry bandage, and, from time to time, movements
were undertaken. He received a corroborating diet, and went on pretty well;
when, three weeks after the operation, the tpot was taken with erysipelas, which
is almost endemic in that hospital.

A fortnight after his restitution, when the movement of the toes, and even of
the ankle joint, had been established, hospital gangrene broke out in the wards,
with which he was very dangerously affected. Our usual remedy, cataplasms of
grated carrots, and the internal use of decoction of cinchona with aromatic tinc-
ture and acids, restored the man, after that even amputation had been taken into
consideration. From the seventh week the convalescence went on without fur-
ther interruption. Active and passive movements took place every day ; and
with the beginning of December the first essays of walking could be made with-

542

Progress of the Medical Sciences.

[Oct.

out mncli pain or difficulty. The 26th December the man left the hospital, quite
restored to health, his foot being cured. The wounds closed ; position and move-
ment normal; no deformity; the shortening of the limb l^cm. (six-tenths of an
English inch) ; the sole something fiat ; the back of the foot of a quite normal
form ; sensibility, temperature, and the colour of the skin like that of the other
foot.

Case 2. Ludwig Susemuhl, 14 years old, baker, of a delicate complexion, fell
in the beginning of the month of October, 1860, and got a distortio in articulo
pedis, whose consequences had not yet quite disappeared, when he fell a second
time, and hurt the same ankle-joint in a very painful way. When he entered
the hospital for workmen, on the 10th November, we found an irreducible dis-
location, a considerable swelling of the foot, great painfulness, which increased
by touching or movement; inability to walk. Twenty leeches, and fomentations
with aqua saturnina could only allay the pains and inflammation, but not change
the general state of the foot; nor could the local application of unguents, and
the internal employment of nitrate of soda cure the symptoms of a local chronic
inflammation and a general state of fever. Abscesses, which formed on the
inner side of the ankle-joint during the month of December, were opened, and
gave issue to a laudable pus. They corresponded to a rough, carious, and soft-
ened part of the astragalus. The whole bone proving carious, and the neigh-
bouring bones being intact. I proceeded, on the 28th of December, to the
removal of the diseased astragalus. As I believe it of great importance in all
resections that the wound of the skin should coincide as little as possible with
the defect in the bones (the former should be as far as possible from the latter),
I made a real gaiter-like incision (like that of Baudens for the ex-articulation of
the ankle-joint) . Continuing, as in the former case, and finding the bone not as
firmly attached, I succeeded in keeping sound all the extensor tendons, and in
removing the bone in two halves. The tendons being isolated, and kept aside,
I introduced the chain-saw, and divided the astragalus in an oblique line. No
bloodvessel being to tie, I adopted the same bandage and treatment as in the
former case. The local success being almost as good as after the first opera-
tion, the symptoms of tuberculosis pulmonum et intestinorum showed themselves
more and more ; the wound got gangrenous ; and in the end of January he died
with phthisis generalis. The post-mortem examination proved lungs and bowels
covered with tuberculous deposits, and the wound of the foot filled with un-
healthy pus, notwithstanding its partial reunion.

If we add these two cases to the rest, the operation has been done in seventy-
eight cases since the year 1670, when Fabricius Hildanus performed it for the
first time. After him it has been executed by Broglie, Aubray, Ferrand, De-
sault (five times), Manduyt, Laumonier, Rumsey, Trye, Hey, Charley, Daniel,
Percy, Roux, Dupuytren (four times), Evans, Green, Lynn, A. Cooper (twice).
West, Stevens, Follot, Nowood, Cloquet, Arnott, Thierry, Norris, Heidenreich,
Hinterberger, Rognetta, Dietz, Quetalet, Yelpeau (twice), Robert, Wackley,
Chabanon, Thore, Letenneur (twice), Statham, Estevenet, Hancock, Adden-
brock, Smith (eight times), T. F. Heyfelder (twice), Chassaignac (twice), Gis-
borne. Husband, and the Author (twice). Partial resections have been made
by Moreau (the father), Duverney, Rattley, Champion, and another English
surgeon whose name I do not know. So that five out of 78 were partial — 73
total; 11 of the 78 operated on died, 67 lived. Of this 67 operated on, whose
lives were preserved, two were afterwards subjected to amputation — one for de-
formity and uselessness of the member; 65 were fully restored. The fatal cases
form, consequently, one-seventh; the unsuccessful ones, one-sixth of the total
number.

Ankylosis of the ankle-joint is not at all, as Boyer pretends, the necessary
consequence of the operation; as, out of the 67 successful cases (which generally
are not even extensively enough communicated) I found 10 in which the mova-
bleness of the foot, or even the formation of a new articulation was established
and expressly named. Ankylosis may, of course, take place by very acute in-
flammatio-n, by want of passive and active movements, or by retraction of exten-
sive cicatrization, as it happened in one of Chassaignac's cases.

The indications for this operation are exceptionally caries or necrosis ; usually

1862.]

Surgery.

543

traumatic injuries (69 times out of 78), these may be gunshot wounds, or frac-
tures, or complicated luxations ; the latter are the most frequent cause for the
extirpation or resection of the astragalus ; 68 out of 78 cases were operated on
for this reason. Not only luxations complicated with fracture (twice out of 68
times), with wounds, with secondary disease of the bone, but even fresh and sim-
ple luxations, which cannot at all, or not without much difficulty and power be
reduced, should rather indicate the partial or total resection, as Dupuytren
{Annuaire MM. His. des Hop. de Paris, 1819, p. 28) did in one case with fall
success. On the contrary, I believe that in my second case, and in one observed
by Professor Bruns [Deutsche Klinik, 1857, pp. 479, 480), where the man died
without having been operated on, an early resection of the astragalus might
have saved the life.

32. Compound Comminuted Fractures of the SJcull. — Dr. A. Wynn Williams
read a paper on this subject before the British Medical Association at its late
meeting. The author, after some general remarks on injuries of the head, related
briefly a few cases which had come under his care.

The first case is that of R. E — , aged twenty-eight, who consulted me in May,
1851. He was a fine, powerful man, but of exsanguined appearance. He in-
formed me that two years and a half previous to his consulting me, whilst work-
ing in Mr. Assheton Smith's slate quarry, he was struck on the head by a small
piece of slate rock, which had been thrown by the force of a blast of gunpowder
a considerable height into the air, and afterwards fell perpendicularly on his
head; he was knocked down and rendered senseless by the force of the blow,
and remained considerably confused for some days. He so far recovered as to
be able to walk about; but from debility had been unable to do any work from
the date of the accident. The patient was attended at the time by the " bone-
setter," who, as the man stated, did nothing but put a bit of plaster on his head;
he had also been seen at different times by several surgeons, who had not thought
it advisable to interfere in the case. The man had had a wound in his head
since the occurrence of the accident, through which three or four small spiculse
of bone had on various occasions worked out. On examining his head, I found
a depression over the upper and frontal end of the right parietal bone, in the
centre of which was a fistulous opening discharging offensive pus. Introducing
the probe, I detected several pieces of loose bone. I made a crucial incision
through the integuments, and, after dissecting back the flaps, perceived a fissure
in the skull, of about half an inch from before backwards, and somewhat less
from side to side. After cutting away the callus that partially filled it up, I
succeeded in picking out eighteen small roughened spiculse of bone. I could
then distinctly see the pulsations of the somewhat roughened dura mater. Con-
sidering it possible that there might be still some spiculse remaining, I filled up
the wound with lint to prevent its healing. At the .expiration of a week, finding
that the wound continued to discharge offensive pus, I made another examina-
tion with the probe, and discovered a piece of bone lying under what appeared
to be healthy bone, but which I was unable to draw out with the forceps. Not
liking to remove a piece of sound bone out of my patient's skull, either by the
trephine or the saw, I notched the bone on either side of the opening with a pair
of strong bone nippers, and through the opening thus made succeeded in ab-
stracting a piece of the inner table, quite smooth on its under surface, of the
shape and size of the half of a half-crown piece, together with several smaller
ones. The whole number on this and the previous occasion amounted to twenty-
four. I kept them by me for several years ; but on my removal from Carnarvon
to London they were unfortunately lost. After this the wound closed, and the
man shortly returned to his work.

The second case is that of E. W — , aged thirty-five. He consulted me in
December, 1853. This man received the injury from which he was suffering
about a year and a half previous to my seeing him, in a manner precisely similar
to the man whose case I have just related. The fracture was situated on the
upper and back part of the left parietal bone. I operated in the same way as
in the preceding case, and succeeded in removing all the pieces of loose bone —
three in number — at the first attempt. They were not roughened as in the first

544

Progress of the Medical Sciences.

[Oct.

case, and, witli the exception of one piece removed from my first patient on the
last occasion, were of larger size. This man, after the removal of the loose
pieces of bone, made a rapid recovery.

The third and last case which I shall relate, 0. E — , aged fifty-six, I was re-
quested to see on July 12, 1858. He had met with an accident similar to the
two others three days previous to my seeing him. He had suffered on more
than one occasion, anterior to the accident, from phrenitis. I found him lying
in a state of semi-stupor; occasionally, however, he would become excited and
even violent. On examining his head, I found a starred wound in the scalp,
situated on the right side of the upper and back part of the frontal bone, ex-
tending through both tables. Feeling with my finger some detached pieces of
bone, I at once enlarged the wound in the scalp, and removed five fragments of
bone. I filled the hole with lint, and placed a piece wrung out of cold water
over all, giving orders to have it renewed when necessary; prescribed a pill con-
taining two grains of soap-and-opium pill and extract of henbane, and one grain
of calomel, to be taken every four hours, with a saline mixture. To have milk
diet. I did not see him again until the 14th, when I found him quieter and more
rational, and he had had several hours' sleep. Ordered to take the pills and
mixture three times a day. On the 17th, finding that his bowels were acting
too freely, a chalk mixture with aromatic confection was substituted for the
saline. I3is gums became slightly affected on the 22d, The pills were then
discontinued ; but as there was still more or less restlessness and irritability of
the system, a saline draught with four drops of Battley's solution of opium was
given three times a day. From this date he progressed steadily, requiring no
medicine except an occasional aperient. The wound was, however, kept open
by means of tents ; and on the 18th of August I succeeded in removing with the
forceps three more fragments of bone, after which the wound healed up ; and
my patient returned to his work six weeks after the date of the accident. I
may here mention that the medicines, more particularly the calomel, were pre-
scribed more on account of his antecedents than because of the accident. In
the February following, whilst at work in the quarry, he was again attacked
with phrenitis, and died. I did not see him at the commencement of the illness,
but was informed that he had been drinking hard several days previous to the
attack. From the appearance of the cicatrix over the seat of the injury, and
taking into consideration the fact that prior to the accident in July he had suf-
fered from similar attacks, I think that the injury to the head seven months pre-
viously had little or nothing to do with his death.

It may be considered remarkable that such serious injuries could have been
inflicted on the skull without injuring at the same time the brain or its mem-
branes beyond the mere concussion ; but when it Is remembered how readily the
shell of an egg may be broken without injury to the membrane by which it is
lined, when struck by a peculiar, sharp, and at the same time light blow, the
fracture of the skull without' injury to the dura mater need no longer be a cause
of surprise.

The splintering of the inner lamina of the skull to a greater extent than the
outer has until very lately been attributed to its greater brittleness. Mr, Erich-
sen, however, does not consider this to be the only cause. He remarks: "I
should rather attribute it to the direction of the fracturing force from without
inwards, causing a certain loss of momentum in passing through the outer
table ;" and instances the case of a man who discharged a pistol into his mouth,
the bullet passing out through the vault of the head, the larger fracture being
in the outer lamina. For my part, I think there is another cause besides brit-
tleness of the inner table, or the loss of momentum in the fracturing force, and
I hope to demonstrate to you, and this meeting, that this third cause is the main
one. The support given to the layer first struck by the layer last struck prevents
the former from being fractured to the same extent as the latter, which has no
such support. For instance, take a piece of slate and knock a hole through it
with a sharp-pointed hammer, and the place of exit will be considerably larger
than the place of entrance. Now, as either side of the slate is equally brittle,
we may, I think, dismiss the different degrees of brittleness without further com-

1862.]

Surgery.

545

ment. As regards the loss of momentum, suppose we take a piece of slate rock,
of somewhat less than a quarter of an inch in thickness, and split it into three
thin slates ; take two of these slates and place them in exact apposition ; strike
them with the pointed hammer with sufficient force to drive it through both,
and of course the slate last struck will have a larger hole in it than the one first
struck; but if you now place the three slates in exact apposition and strike
them with the hammer, you will find, on examining them, that there is little or
no difference between the first and second struck, because the first was supported
by the second, and the second by the third ; whereas the hole in the third will
be considerably larger than in the first or the second, because it had no support
at the point of exit.

It is the opinion of all writers of the present day on injuries of the head, that
when small fragments of bone are driven down upon the dura mater, inflamma-
tion is almost certain to be set up and be propagated to the brain. The late
Mr. Liston writes : " The presence of numerous sharp spiculae of the internal
table for even a short period upon the surface of the dura mater (and the more
so if any of them have penetrated) is almost uniformly followed by internal in-
flammatory action, propagated to the brain and its more immediate investments."
Prescott Hewett, in Holmes's System of Surgery, says : "But in the punctured
fracture, in which sharp splinters of the inner table are driven down upon or
into the dura mater, inflammation almost invariably arises sooner or later; and
of all compound fractures of the skull, the punctured fracture is on this account
the most dangerous, and the one which most imperatively calls for the use of
the trephine." Erichsen states : " In the punctured fracture it (the trephine) is
applied, not to remove symptoms of compression, which in all probability may
not exist, but with the view of preventing inflammation, which would to a cer-
tainty set up if the splinters of the inner table were allowed to continue irritating
the membranes or brain. Hence it is a rule in surgery, in all cases of punctured
fracture, to apply the trephine at once, so as to prevent the injurious after-con-
sequences which must otherwise necessarily arise."

I need not detain you longer quoting opinions. Suffice it to say that all
modern writers express very much the same opinion. I cannot help expressing
some surprise that men of such high professional attainments, and who are en-
gaged in propagating surgical knowledge, should all express the same opinion,
and in very much the same words. I think you must agree with me, after the
history of the few cases I have read to you, that no such intense inflammatory
action is likely to be set up, and also that unless the brain and its membranes
have themselves received injury at the time of the accident, either laceration,
contusion, or compression, no brain symptoms beyond what is produced by the
concussion are likely to occur. In the first case, numerous sharp spiculae of
bone— probably not so numerous as they afterwards became, owing to the natural
process of removal wherever the fragments were surrounded by healthy granula-
tions— lay in contact with the dura mater for the period of two years and a half:
in the second case, a year and a half ; and in the third case a portion of the frag-
ments were allowed to remain five weeks ; without in either case exciting more
inflammatory action than would have been set up in a similar injury inflicted on
any of the other flat bones of the body. The amount of pus secreted is not more
than is required for the natural process of repair. It is only, as in other parts
of the body, when matter is allowed to lodge and burrow between the membranes
and the bone, that it becomes injurious. This I have seen exemplified in cases
where there has been a comminuted fracture without a wound in the scalp. In
such cases, when pus is formed, it has no outlet, and generally burrows between
the dura mater and the bone, creating irreparable mischief, if without delay the
surgeon does not turn the non-compound fracture into a compound one. by
making an incision through the integuments. By thus giving exit to the pent-up
matter, all symptoms of compression and injury to the brain will cease.

I have only discovered one author who has written on injuries of the head
who appears to agree with me in believing that the brain and its membranes are
not particularly prone to take on inflammatory action, and this is that very
talented writer and accurate observer of Nature, and all her efforts at repair,
No. LXXXYIIL—OcT. 1862. 35

546

Progress of the Medical Sciences. [Oct.

Sylvester O'Halloran,' of Limerick, who published a work on External Injuries
of the Head in 1793 (only a few years after Percival Pott published his work),
wherein O'Halloran very justly blames Pott for his rash and unjustifiable abuse
of the trephine. He at the same time calls in question Mr. Pott's and other
previous authors' antiphlogistic treatment of injuries of the head, on account,
as they presupposed, of " a high tendency to irritability and inflammation in the
cerebrum and its coverings." He goes on — "But is this supported by facts?
It undoubtedly is not ! Every observation proves they have very little tendency
to either ; at least the most violent external injuries offered to them establish
the fact." Further on he writes — "To a certainty, then, neither the brain nor
its envelopes are subject to inflammation or irritability, at least from external
hurts."

With regard to the treatment of such cases, I have little more to relate than
has been already stated in the history of the cases. Of course as there is little
tendency to that bugbear inflammation, you need not bleed your patient; but
after the immediate effects of the concussion are gone, an opiate will often give
great relief to the peculiar restlessness of the patient. As regards other reme-
dies, your patients will, as a rule, do as well without them as with them. Sur-
gically, they should be treated on the same principles as would guide you in
treating comminuted fracture in other parts of the body. There is, however,
one surgical point which I most particularly wish to impress on the members of
this Association and others : it is the advisability of substituting, when compel-
led to operate in a case of fracture of the skull, the bone-nippers (wrongly called
bone-forceps) for the trephine and saw. If the operator can only introduce the
point of one of the blades through the fractured bone, he will be surprised to
find how readily he can enlarge the opening in this or that direction as might be
deemed necessary, without removing more of the skull than is absolutely required
for the extraction of the loose pieces or the liberation of those depressed. —
Lancet, Aug. 23, 1862.

33. Old Dislocations and their Treatment. — Mr. B. E. Beodhurst commu-
nicated to the Royal Medical and Chirurgical Society (June 10, 1862) some
observations on this subject. The object of his communication was to show
that dislocations might with great advantage be reduced at a much later period,
now that chloroform is in use, than formerly; yet the author contended that this
fact has in great measure been overlooked, and that the teaching of Sir Astley
Cooper — namely, eight weeks for dislocations of the hip, and three months for
those of the shoulder, was still all but universally observed. He referred to the
obstacles to the reduction of old dislocations, and he then considered the means
of overcoming them. He pointed out two great distinguishing features of old
dislocations — namely, on the one hand, the recovery of motion and the formation
of a new joint ; and, on the other, a painful position of the head of the bone,
together with a motionless condition of the limb: and he suggested that inter-
ference was to be deprecated when motion was being restored and the new joint
was becoming perfect, but that reduction might at anytime be attempted whilst
the limb remained motionless and painful. A case was related of a muscular
man, fifty-three years of age, who, having dislocated the humerus beneath the
pectoral muscle, came under the author's notice when the dislocation had existed
nearly six months. The author reduced it on the 175th day. The reduction
was most easy and immediate ; there was no disposition for the bone again to
become displaced, and the patient recovered almost the entire use of the limb.
In conclusion, it was observed that extension ought not to be employed primarily
in the reduction of old dislocations, and the argument adduced was as follows :
The adhesions round the head of the bone must always be ruptured prior to
reduction. If they are ruptured by the use of the pulleys, so much force is
required in extension, when the dislocation is old and the adhesions are tough,
that there is danger of rupturing the muscles and breaking the neck of the bone;
but if they are ruptured by to and fro movements the pulleys are unnecessary
to replace the limb, traction and manipulation being sufiicient for this purpose.

1 I have to thank Dr. O'Connor for the knowledge of this work.

1862.]

Surgery.

5i1

The author summed up thus: " With chloroform, no precise time can be set as
a limit to the reduction of an old dislocation. When useful motion is being
regained — when the new joint is being formed, and pain has subsided, attempts
at reduction may be deemed unjustifiable; but while the limb remains painful
and motionless, the dislocation is reducible, and it ought to be reduced."

Mr. Pollock said that Mr. Brodhurst had only adduced one case in support
of his plan of treatment. It was not uncommon for dislocation of the shoulder-
joint to be reduced under chloroform after an interval of five or six months.
He (Mr. Pollock) related some cases in point. He thought that Mr. Brodhurst
would modify his opinions with respect to the use of the pulleys in cases of old
dislocation of the hip-joint. When extension was made in the right direction,
under chloroform, these dislocations were to be reduced with more facility by
the pulleys than by any other means. He alluded to those cases in which the
head of the thigh-bone was dislocated into the ischiatic notch. It was not ne-
cessary that pulleys should be used in cases of dislocation of the shoulder-joint.
He inquired if Mr, Brodhurst had had any experience in the reduction without
pulleys of long-standing cases of hip-joint dislocation.

Dr. Wtnn Williams said it was his lot to practise for a good number of
years in a neighbourhood where nearly all fractures and dislocations were treated
by what were termed "bone-setters ;" consequently he had had under his care
numerous cases of unreduced dislocation. Now, if the teaching of the London
Schools was still such as stated by the author of the paper, he (Dr, Williams)
could only say that practice had shot far ahead of teaching. He could answer
for himself as well as for his brother practitioners practising in the vicinity of
the Carnarvonshire and Merionethshire slate quarries, that since the introduc-
tion of chloroform they had followed no general law, but had attempted the
reduction of old dislocations whenever there appeared to be any chance of suc-
cess. He could call to mind two cases in his own practice which would fully
bear out what he had stated. The first was that of a man who consulted him
as to the possibility of reducing a dislocation of the elbow-joint of four months'
standing. It had been caused by the man having fallen from a load of hay, his
right forearm passing through the riples of the cart and arresting his further
descent. The bones of the forearm were driven backwards on to the humerus.
He had been under the care of a bone-setter, who, instead of reducing the dislo-
cation, placed and kept the arm in a perfectly straight position, so that it hung
useless by the man's side. Dr. Williams found the joint immovable; indeed, it
appeared as if union had taken place between the bones of the upper and fore-
arm. He placed the man fully under the influence of chloroform, and applied
extension by pulleys for some time, using considerable force, but without any
effect. He then placed his knee in the elbow, and suddenly bent the forearm on
the arm, and felt a distinct crack, as if a bone had broken. It was caused by
the separation of the ulna from the humerus, a small portion of the former (a
fragment of the olecranon) remaining attached to the humerus. After this re-
duction was not difficult, and the man acquired a very useful arm. The other
case was that of a boy between eight and nine years of age who, having fallen
from a height with his legs separated, dislocated the left hip-joint. He had
been attended by a bone-setter for about five months previous to being seen by
him (Dr. Williams). He determined to attempt reduction, and went with his
assistant on the following day to do so. After administering chloroform, he
thought he would try to reduce the dislocation in the first instance without using
the pulleys. To his surprise he found no difficulty in doing so. The difficulty
was to keep the bone in its place after it had got there, for the moment he ceased
making extension out it went again. He, however, fixed it in position by means
of a long splint and a pad. But several times in the course of treatment the
little fellow would suddenly start during sleep, and out would go the head of the
bone. He taught the boy's father how to reduce the dislocation and tighten
the bandage, so that the bone was reduced almost immediately. After a few
weeks some thick gutta percha was moulded so as to embrace completely both
buttocks, the gutta percha being brought well round on either side. By this
means he was enabled to keep the head of the bone firmly in position, and the

548

Progress op the Medical Sciences.

[Oct.

last time he saw his patient he was gathering water lilies out of one of the lakes.
— Med. Times and Gaz., June 21, 1862.

34. Inversion in Strangulated Hernia. — Mr. Furneatjx Jordan, Assistant
Surgeon Queen's Hospital, Birmingham, records [Medical Times and Gazette,
June 14, 1862) three cases of strangulated hernia in which he unsuccessfully
resorted to inversion. Mr. J. remarks that the cases recently recorded in which
this surgical remedy has been successfully employed, while none in which it
failed have been published, might lead to an undue estimate of the value of this
measure. The careful study of his own cases, with the successful ones which
have been published, lead him to the following conclusions : —

" 1. Inversion may be performed in appropriate cases with efficiency and deli-
cacy, and without detriment to the patient or to subsequent remedial measures.

"2. It should not substitute but be added to the other methods of treatment
which precede operative interference.

" 3. It will, like the taxis under the complete influence of chloroform, fail in a
very large number of cases of strangulated hernia.

"4. It should be resorted to early or not at all.

" 5. Inversion ought certainly to be avoided if there be actual or suspected
inflammation in the hernial sac or in the peritoneum generally. It should still
more urgently be avoided if there is reason to fear a gangrenous state of the
bowel. Inversion in such cases would probably tear the intestines in the abdo-
minal cavity from the strangulated knuckle in the sac. In sphacelus of the
constricted bowel (I may remark parenthetically) I have freely opened the dis-
eased canal — a point on which all surgeons are agreed; and I have, at the same
time, divided the constriction — a point on which, surprisingly enough, all sur-
geons are not agreed.

" 6. Inversion exercised in proper cases and at the proper time facilitates one
step in the operation — the decisive and complete return of the bowel after divi-
sion of the constricting medium. ^

"7. It is not clear that chloroform may be safely administered prior to inver-
sion of the body. The danger may be twofold : 1. Pressure of the tongue on
the epiglottis and upper aperture of the larynx ; and, 2. Pressure of the abdo-
minal viscera on the diaphragm, and, therefore, on the lungs and heart. When
the body is inverted during chloroformization in cases of foreign bodies in the
larynx, most surgeons, I believe, take the precaution of first making an artificial
opening in the windpipe."

35. Local Gangrene treated hy Oxygen Baths. By M. Latjgter. — M. Reveil
has analyzed the gangrenous parts in some patients, and he has arrived at the
conclusion that the essential cause of gangrene is a diminution or absence of
the oxygen necessary for the integrity of, the life of a tissue. This theoretical
opinion has hitherto led to no practical benefits ; but lately M. Laugier, at the
HQtel Dieu, has founded upon it a mode of treatment which has been highly
successful. A patient having one of his great toes partly mortified, and the
skin under the ankle painful, altered in colour, and also threatened with gan-
grene, had his foot placed in a simple apparatus in which the disengagement of
pure oxygen kept it continually in a bath of this gas. The rapid result was the
arrest of the gangrene, and the return of the threatened parts to the healthy
state. The removal of the eschar in the toe ensued, and the cicatrization was
almost completed. Another patient came into the hospital attacked with spon-
taneous gangrene of the two last toes of the left foot; the adjoining skin, as far
as the articulation of the foot with the leg, was red, painful, and threatened with
mortification. The same mode of treatment was adopted, and after a few days

1 The absence of this advantage occurred in a marked manner in a case to which
I was called in the country, where inversion ivas quite out of the question. An unfor-
tunate difference of opinion between two practitioners caused great delay. Peri-
tonitis supervened. After I liad completed the operation the fold of intestine, when
returned into the abdomen, remained precisely where it was placed within the
inner inguinal ring.

1862.]

Surgery.

549

the gangrene remained limited to the parts first attacked. The adjoining skin
remained healthy and presented no more redness, the pain was very much dimin-
ished, and at the date of the last report there was reason to hope for a favour-
able result, although the patient, as in the former case, was seventy-five years
of age. Hence M. Laugier concludes that, whether the theory advanced be
true or not, oxygen baths rapidly arrest, at least in certain cases, the progress
of spontaneous" gangrene of the extremities. — B. and F. Med.-Chir. Rev., July,
1862, from Bull. Gen. de Themp., May 30, 1862.

36. Contributions to the Statistics of Cancer. — Mr. W. M. Baker communi-
cated to the Royal Medical and Chirurgical Society (July 8) a paper on this
subject.

The cases of cancer from which this paper was constructed were 500 of those
recorded by Mr. Paget between the years 18-43 — 1861, and all of which had
come under his own observation. Only the external or so called surgical can-
cers were included in this number. The first part of the paper showed the pro-
portion of cases in each organ and each sex, and the percentage of the several
kinds of cancer — each part of the body being attacked, as a rule, by one form
of the disease almost exclusively. The greater frequency of cancer in females
was found to be due to cases of scirrhus of the breast ; in the cases, in almost
all the other external organs, especially those subject to epithelial cancer, the
proportion of males was greatest. The influence of age was next noticed, and
the increasing liability to cancer as people advanced in life ; the absolute num-
ber among the 500 cases at each age being given, and also the relative frequency
in proportion to the whole population living at the same period. In external
organs, medullary was found to be the most frequent variety in youth ; scirrhus
and epithelial in middle and old age. The number of females affected with
cancer, in proportion to the whole population, was found to increase rapidly
from the earliest age up to 40 — 50. and then more gradually decline. In males
the number increased up to the age 50 — 60, and after this declined again, the
rise and fall being both of them more gradual than in females. The kind of
cancer to which each sex was most liable accounted for the difi'erence. The
condition of the female patients — whether single, married, or widow — was no-
ticed, and also the influence of each on the production of cancer. The propor-
tion of cases of cancer in the breast was found to be greater in the married than
in the single, both absolutely and in proportion to the number in which the two
classes exist in the community. The state of health of the patients at the time
of the beginning of the disease was ascertained, and found to be good in a very
large majority; a rather larger proportion of the medullary and epithelial than
of the scirrhous being in bad health at this date. The question of cancerous
inheritance was in the next place considered, and answered in the affirmative,
24 per cent, of the patients giving a history of" cancer in other members of the
family; the percentage, too, in tlie private cases, in which the family history
would be better known, was considerably greater than in the hospital. The
variety of cancer was not always the same in all the members of the family at-
tacked. Tables of the date of recurrence after operation were given, and the
several kinds of cancer compared in this respect; the average number of months
which elapsed between the date of removal of the primary disease and the recur-
rence, was greatest in scirrhous, and least in epithelial, but a larger proportion
of cases of the last variety remained without any recurrence for a period far be-
yond the average. The date of recurrence after early and late operation was
compared; the difference between the two. being but small, probably from the
acute cases being the earliest to be removed and to return. One or two of the
cases, remarkable by their long-deferred recurrence were given more in detail.
The last part of the paper was devoted to considering the duration of life, espe-
cially with the object of comparing the cases of operation with those in which
the primary disease was not removed. The greatest difference in the two sets
of cases was found to exist between the epithelial cancers, and the least between
the medullary ; but a marked increase of life on the side of the operations was
present in all the varieties. Part of this result is, of course, due to the selection
of cases for operation. Some of the organs were compared separately, and the

550

Progress of the Medical Sciences.

[Oct.

same advantage on the operation side was shown in each, with one exception —
viz., the bones, in which the duration of life was exactly the same on both sides.
The influence of early and late operations in respect to the duration of life was
also considered, and as in the recurrences, only a slight difference was observed ;
indeed, the length of life was greater in the cases in which the operation was
performed at two to five years after the first observation of the disease than in
those at one to twelve months, the former being all chronic cases. Lastly, the
duration of life in the hospital and private cases was compared, and the advan-
tage shown to be on the part of the hospital. Some of this difference may. how-
ever, be accounted for by a large number of the hospital cases being submitted
to operation. — Med. Times and Gaz., July 19, 1862.

OPHTHALMOLOGY.

37. Amaurosis consequent on Acute Abscess of the Antrum, produced hy a
Carious Tooth. — Mr. S. J. A. Salter read before the Royal Medical and Chi-
rurgical Society (June 24) a paper based on a case of this kind of unusual
severity and of exceptional complications. The patient, a young woman, 24
years of age, was attacked with violent toothache in the right upper first molar,
which was followed by enormous swelling of the side of the face, and intense
pain. The eyeball then became protruded, and she soon after perceived that
the eye was blind. Shortly after the establishment of these symptoms, " abscess"
of the antrum pointed at the inner and then at the outer canthus, and a large
discharge of pus at both orifices followed; these orifices soon closed, and the
general symptoms of the part continued unchanged — the swelling of the face,
protrusion of the globe, and blindness. This state of things lasted for about
three weeks, when the patient was sent to Guy's Hospital, and admitted. At
this time the patient exhibited hideous disfigurement from swelling of the face,
cedema of the lids, and lividity of the surrounding integument. Upon examin-
ing the mouth, it was found that the carious remains of the first upper right
molar appeared to be associated with, and to have caused the disease. Together
with the outer contiguous carious teeth this was removed, and led by an ab-
sorbed opening into the floor of the antrum. The hemorrhage which followed
the operation was discharged partly through the nose and partly through the
orifices in the cheek, as well as from the tooth-socket, showing a common asso-
ciation of these openings with the antrum. The condition of the eye constituted
the most important symptom, and the most distressing. The sight was utterly
gone ; the globe prominent and everted. There was general deep-seated inflam-
mation of the fibrous textures of the eye. The pupil was large and rigidly flexed ;
it did not move co-ordinately with the other under any circumstances. Some
abatement of the symptoms followed the extraction of the tooth ; but it was
soon found that there was a considerable sequestrum of dead bone, which was
removed. The necrosis involved the front part of the floor of the orbit, the
upper cheek portion of the superior maxilla, with the infra-orbital foramen, and
a large plate of bone from the inner (nasal) wall of the antrum. The removal
of the dead bone was followed by the immediate and complete cessation of all
inflammatory symptoms; but the eye remained sightless, and the pupil rigidly
fixed. About five weeks after the removal of the dead bone, it was noticed that
the pupil of the affected eye moved with that of the other, under the influence
of light, though vision in it had not returned. The eye was frequently examined
at this stage with the ophthalmoscope. All the structures, including the retina,
appeared healthy, except the termination of the optic nerve, which was per-
fectly white and anaemic, while that of the other eye was pink and natural. The
author referred to two other cases essentially similar to his own. The first
(unpublished) occurred in the practice of Mr. Pollock, of St. George's Hospital.
The patient had intense inflammation of the entire maxillary region on one side,
caused by a carious tooth. It implicated the whole face and the contents of

1862.]

Ophthalmology.

551

the orbit, but was not attended by " abscess" of the antrum or necrosis of bone.
The inflammation completely ceased on the removal of the tooth, but the sight
was permanently lost ; the pupil was at first fixed, but afterwards moved with
that of the other eye. Another example, closely resembling these, was pub-
lished by Dr. Briick, in Casper's Wochenschrift for 1851. It was, however,
more chronic, and the loss of vision was only temporary. The author concluded
his paper by suggesting that the serious ophthalmic symptoms depended on the
nerves of the eye being involved in a plastic inflammation in their course, ex-
ternal to the skull, and before their distribution ; that the optic nerve was per-
manently damaged, as shown by the permanent blindness ; that the third nerve
was temporarily implicated, as shown by the temporary fixedness of the pupil ;
and the eversion of the eye from the first seemed to indicate that the sixth
nerve was less or not at all involved. Finally, the author left it an open ques-
tion whether the anaemia of the optic nerve, as displayed by the ophthalmoscope,
is to be looked upon as a cause or consequence of its suspended function. — 3Ied.
Times and Gaz., July 5, 1862.

38. Blepharospasm. — Mr. W. White Cooper has recently {Lancet, June 14,
1862) published some interesting observations on this troublesome affection.

"He has seen," he says, ''very many cases of that troublesome affection of
the branches of the facial nerve which causes twitching of the muscles of the
eyelids and the face ; they have presented themselves in every degree, from the
slight, almost imperceptible quiver of the fibres of the orbicularis, known as
'life-blood,' to firm persistent closure of the lids themselves ; and I may say that
I know of no disorder, not really serious, more distressing to the patient. In
two cases there was also spasm of the throat, so that in one, the patient, a lady,
uttered from time to time aloud 'cluck,' sufficient to attract attention in the
streets; the other sufferer, also a lady, gave utterance to a convulsive sob.
especially when nervous or agitated. These sounds were uncontrollable, were
increased by the desire to repress them, and together with the facial contortions,
led the ladies to seclude themselves from society.

'•The 'life-blood' quivering is the most common form; rapid closure of the
lids, exactly resembhng an intentional 'wink,' is next in frequency. The rarest
and most severe form is firm compression of the lids — so firm that an attempt
at forcible opening will evert but not raise the lid.

"When the convulsive action implicates the muscles surrounding the globe,
the distress is greatly aggravated. A patient of mine suffers from tic douloureux
and spasmodic twitching of the muscles of the left side of the face, together
with an agonizing sensation, as if the eyeball were forcibly dragged back into
the socket.

" I remember a curious case in which the desire for riches proved the source
of an unexpected grievance. A gentleman sold an estate for a large sum, which
• he placed at his banker's till such time as he could invest it profitably. It
became a perfect incubus; day and night the subject was uppermost in his
thoughts. The desired investment always eluded him, and at length the worry
told upon his health, one of the prominent symptoms being convulsive move-
ments of the muscles of the eyelids and left side of the face. He was under my
care for some time, but it was not till after a satisfactory investment had been
made that the truth was disclosed to me.

"One of the causes assigned for this irritation of the facial nerve is the too
free use of stimulants. I certainly have in a few instances thought this to be
the case, but in the majority it assuredly was not so; indeed, many of the
patients have been most abstemious. Nevertheless, it is a point to be borne in
mind, and patients should be directed to be careful as to their diet, and if spirits
are indulged in, they should be forbidden ; light wines are less objectionable.
The treatment which, on the whole, I have found most successful has been,
topically, counter-irritation at the nape of the neck and behind the ears (a speedy
and powerful rubefacient is pepper sprinkled on a wet rag and applied to the
skin ; it is more cleanly and even more active than a mustard plaster), and fric-
tion of those parts with an embrocation composed of one part of extract of
belladonna, one part of soap liniment, and two parts of cajeput oil.

552

Progress of the Medical Sciences.

[Oct.

" It is not, however, on local treatment that too much reliance should be placed.
The medicines which have appeared to exert most influence have been the
ammonio-citrate and citrate of iron combined with the tincture of sumbul and
with valerian, the bowels being carefully regulated with mild aperients, such as
the aqueous extract of aloes with soap and belladonna. A very constant feature
in the worst cases has been a tendency to constipation — a condition which has
been decidedly relieved by belladonna. This I had myself noticed, and find the
fact confirmed, and thus explained, by Schrceder van der Kolk: —

' This medicine (belladonna) acts specifically on the intestines. Thus laxa-
tives— for example, watery extract of aloes, with the addition of belladonna —
are exceedingly useful in heartburn, spasms, and especially in constipation,
which long experience and a great number of post-mortem examinations have
satisfactorily proved to me to be almost always dependent on constrictions in
the descending colon. This state, moreover, exercises a powerful reflex action
on the brain and medulla oblongata, as is shown by the melancholy with which
it is so often connected. In these cases the stricture is removed, and the laxa-
tives act infinitely better in consequence of the addition of belladonna. I sus-
pect that it is in this the principal use of the remedy lies, which is recommended
by so many in epilepsy, though they do not state the indication for its employ-
ment in that disease.''

" In some instances where acidity was strongly marked, alkalies afforded much
relief."

[In some cases of this troublesome affection we have found the valerianate of
zinc beneficial. — Ed.]

39. Paracentesis of the Cornea. — Mr. Geo. Lawsox relates ( The Royal Lon-
don Ophthalmic Hospital Reports, Jan. 1862) some cases illustrative of the
advantages of tapping the anterior chamber of the eye in cases of sloughing
ulcers of the cornea, or of ulcers which refuse to heal under other modes of
treatment ; in cases of onyx, or of ophthalmitis with hypopion.

"The operation," he remarks, "is a simple one, and best performed by the
manner usually adopted by the surgeons at jNLoorfields, viz., by passing a broad
needle through the cornea at its lower margin, keeping the point well forward
towards the cornea, to avoid wounding the lens, and then suddenly turning it on
its edge so as to allow the aqueous to run off, and rapidly withdrawing it, as
soon as the iris approaches the cornea.

"The indications which call for this line of treatment may be briefly stated.

" 1st. Increased tension of the globe. The eye, in any of the above-mentioned
cases, may have its tension slightly increased, and this seems, in a great measure,
to depend on an increased secretion of the aqueous, for the anterior chamber
becomes deepened; and this is specially observable when contrasted with that of
the other eye, and the iris, instead of presenting a plane surface, slopes backwards.

"2d. Deep ulcers which threaten to perforate the cornea will often rapidly
assume a healthy action after the tension of the cornea has been diminished by
letting off the aqueous humour; and sloughing ulcers will, under the same treat-
ment, derive similar benefit.

"That this benefit is often only transitory is true, but the operation is so sim-
ple, that it may be repeated an indefinite number of times, if the patient after
each derives relief.

"3d. In cases of onyx or pus between the laminge of the cornea, the relief of
the tense state of the cornea promotes absorption, and relieves pain, and so
places the eye in a favourable condition for complete recovery. An onyx which
threatens to burst backwards, can be most safely combated by tapping the ante-
rior chamber of the eye in addition to the use of other remedies.

" 4th. This operation relieves pain, and, if carefully and properly performed,
can do no harm. The relief of pain is so remarkable, that patients, on their
next visit to the hospital, will, unasked for, relate the great benefit they derived
from what had been done to the eye; but at the same time they will often state
that after about twenty-four hours the pain was nearly as bad as ever. The

1 On the Spinal Cord and Medulla Oblongata, p. 275.

1862.]

Ophthalmology.

653

truth being that the aqueous had become completely restored, and that the ten-
sion which called for the first tapping was as great as ever.
"The operation in such cases should be repeated."

40. Periorhitis. — Mr. W. White Coopee makes the following interesting re-
marks on this affection: "A rare but very dangerous affection is acute inflam-
mation and suppuration of the cellular tissue of the orbit ; primarily dangerous
from the tendency of the inflammation to extend to the dura mater; and should
this complication be escaped, there is still much risk of caries of the bones of
the orbit, leading to tedious suppuration, exfoliation, and possible deformity.

"Two fatal cases are recorded by Dr. Abercrombie ;i death in each case fol-
lowed acute inflammation of the dura mater. In one, a lad of fifteen, the frontal
bone was found denuded and carious to a considerable extent, and the upper and
back part of the orbit was also denuded. In the other case, the suppuration
was limited to a circumscribed cavity in the orbit, without disease of the bone.

" A very marked example of this disease came under my notice during the
past winter. It occurred in the practice of Mr, Joyce, of Berkeley-gardens,
who informed me that he was summoned to the patient, a fine boy sixteen
months old, in consequence of his having passed a restless night, tossing and
screaming much. The only thing noticeable was a peculiar haziness of the left
eye. Mr. Joyce at first suspected measles, but in the evening observed that
the lower eyelid had begun to swell, which swelling increased with extraordinary
rapidity. The treatment adopted was most judicious ; nevertheless, the tume-
faction increased, and I was summoned about thirty-six hours after the com-
mencement of the attack. My first impression was that the case was purulent
ophthalmia, so closely did the livid, enormously swelled eyelids resemble that
disease. The total absence of discharge at once dissipated the idea, and on
close inquiry it appeared that about a month previously the child had sufi'ered
from a carbuncle, that he had never since been well, starting and screaming in
his sleep, with other indications of constitutional disturbance. The conclusion
arrived at by Mr. Joyce and myself was, that there was diffused cellular inflam-
mation of the orbit. Active measures were adopted, nevertheless the child
became drowsy, delirious, and unable to recognize those about him. The
symptoms being thus grave, the assistance of Dr. Sibson was obtained, and the
alarming cerebral disturbance subsided under brisk purgation, counter-irritation
of the back, &c. The swelling of the eyelids increased, there was great chemo-
sis, and the' eyeball became projected forward and motionless. Under these
circumstances, I made a deep incision beneath the eye, carrying it well into the
orbit, from which issued a large quantity of thin pus. Marked relief followed,
the tumefaction gradually subsided, and in the course of a few days the eye
recovered to a considerable extent its position and power of motion, although
purulent discharge continued for some weeks ; this, however, ceased on the ex-
foliation of a fragment of bone about the size of a threepenny-piece, evidently
part of the floor of the orbit. When I last saw the child, on the 27th of March,
slight thickening of the lower lid, but without eversion, was the only indication
of this formidable attack.

" I have seen several instances of orbital inflammation with effusion without
proceeding to suppuration. In every case the patients have been much out of
health, and with feeble circulation. The symptoms have been deep-seated pain
in the orbit, swelling of the hds, and protrusion of the eye, with much serous
chemosis. The movements of the globe were impaired. Full doses of opium,
with quinine and steel, appeared to act more beneficially on these cases than
depletion. The recovery is usually gradual, a considerable time elapsing before
the eye recovers its full mobility and perfect position. A person once the sub-
ject of this attack is liable to a recurrence."

Mr. Cooper says that he has "also seen several cases of chronic periorbitis ;
and the remedy which afforded marked and very decided relief was the iodide
of potassium combined with sesquicarbonate of ammonia; but the iodide re-

' Pathological and Practical Researches on Diseases of the Brain, &c. Third
edition, p. 28.

554

Progress of the Medical Sciences.

[Oct.

quired to be given in doses of five grains thrice daily : smaller doses did not
produce any marked effect. It is best to order this medicine to be well diluted
and taken soon after a meal. I can also speak favourably of iodide of sodium,
which appears to depress the system less than iodide of potassium, and is less
liable to create that distressing flux from the nose often caused by the latter.
One point is deserving of attention : these salts should never be prescribed with
liquor cinchonse and water, or an insoluble deposit — iodide of quinine — will be
thrown down. If the tincture of cinchona be used, this does not take place, the
spirit retaining the iodide of quinine in solution." — Lancet, June 7, 1862.

[We have now under our care a case of chronic periorbitis, which is interest-
ing from the fact that the patient suffered from a previous attack nearly fifteen
years ago, and, after an interval of fourteen years, has had a recurrence of it.
He is taking the syrup of proto-iodide of iron with advantage. — Editor.]

41. Epiphora— M.r. W. White Cooper expresses the opinion [Lancet, June
7, 1862) that "slitting up the canaliculus is a valuable operation," but he says
it "disappoints expectations in one class of cases; at least, such has been the
statement of several patients who have consulted me after having undergone
the operation. The cases to which I refer are those in which no inconvenience
is experienced when the patient is in a warm room or still atmosphere, but
exposure to cold, especially damp cold wind, excites a profuse watering of the
eyes, which is a source of great discomfort. It appears to me that in such cases
the fault is less in the tear-ducts than in the secreting organs ; in other words,
it is not that the channels are morbidly contracted, but that the flow of tears is
too great, and is due to an extreme sensibility of the surface of the eyes from
undue excitability of the branches of the fifth pair of nerves, whereby the
lachrymal gland is over-stimulated. The treatment should be directed to this
point.

"As a rule, I am by no means an advocate for covering the eyes too much,
and think that the very general custom of wearing veils is productive of more
harm than good. But much comfort is derived in the cases in question from
the use of a gauze shade to protect the eyes from the current of cold air. By
some patients preference is given to protectors, the glass being encircled with
gauze side-pieces ; this material is preferable to metallic wire, which is too
heavy, and is too much influenced by temperature. I disapprove of the metallic
wire eye-protectors, which are joined together and fixed on the head by elastic
bands. The pressure of the frames against the edge of the orbit is- painful, and
the constriction of the band around the head is absolutely hurtful."

[It seems to us that the only class of cases in which slitting up the canalicu-
lus— an operation so indiscriminately now practised in England — can be re-
garded as useful, is where the lower punctum is everted so as to be incapable
of performing its functions. In other cases we conceive dilatation to be prefer-
able, for we have found the canaliculus to be as easily dilated as any part of the
lachrymal passage.

We can add our testimony to that of Mr. Cooper as to the injurious eflect of
the elastic bands of the wire eye-protectors. We always advise our patients
who require those protectors to eschew the elastic bands, and to use such as
are fixed to frames like ordinary spectacles. These stand out a short distance
from the eyes, and allow of the circulation of air, and do not constrict the
head like the elastic bands. — Editor.]

42. Intra-ocular Elusions and the Ophthalmoscope. By W. White Cooper,
Esq. — " There are no cases in which the advantage of the ophthalmoscope is
more marked than those where the sight has been injured by deep intra-ocular
effusions. The diagnosis of such cases is truly important ; there is probably
nothing abnormal in the external aspect of the eye— nothing beyond some inac-
tivity of the pupil to indicate the serious, too often irreparable nature of the
lesion. The following illustrates the point : — •

"A young gentleman had been educated for the army, and in due course pre-
sented himself for examination before the military surgeons. When the sight
was to be tested, the surgeon placed his hand before the youth's left eye, when

1862.]

Ophthalmology.

555

lo ! he could discern nothing with his right. Another surgeon was called in,
and, after consultation, it was agreed to suspend for six months the final decision
as to his eligibility. Deeply mortified and concerned by this unexpected dis-
covery of his son's blindness, the youth's father brought him to me the following
day. He was a remarkably fine young man, and there was nothing to be seen
under ordinary examination which explained his absence of sight. The only
circumstance bearing on it which he could remember was a severe blow on the
eye from a cricket-ball some six months previously. The ophthalmoscope at
once revealed the nature of the case. There was no retinal reflection whatever ;
a clot of greenish hue, doubtless blood poured out at the time of the blow,
occupied the posterior portion of the vitreous chamber, and completely prevented
all vision. 1 was obliged to express an unfavourable opinion as to the probable
restoration of sight; when a clot has remained so long, with little change beyond
the loss of the red particles, there is small hope of its removal. The difference
between the activity of absorption of blood from the aqueous chamber and the
vitreous chamber is very great; I have seen the aqueous chamber cleared in
twenty-four hours. Slow, on the other hand, is the disappearance of even a
small effusion, when poured into the vitreous chamber ; and when the effusion
is between the choroid and the retina, the latter is detached, and the mischief
irreparable. Of this, two examples have recently fallen under my notice.

"A clergyman underwv^nt violent excitement, which was followed by sudden
extinction of sight in the axis of vision of the right eye. No improvement took
place under treatment, and as his professional prospects were likely to be mate-
rially influenced by this calamity, it was important to ascertain the precise
nature of the lesion, for which purpose he came to town. On testing the sight
I ascertained that the retina was perfect towards the temporal and nasal sides,
but insensible to impressions in the centre. The ophthalmoscope showed the
retina projecting as a pouch at this point, efiusion having taken place between
it and the choroid.

"During the last autumn a gentleman was struck by a shot on the temporal
side of the left upper eyelid; the shot did not penetrate the globe, but passed
on, and lodged on the inner side, where it could be felt between the eyeball and
tendon of the orbicularis. The point of interest was this : the eye had not suf-
fered where the shot had first struck, but on the opposite side sight was extinct.
The ophthalmoscope discovered detachment of the retina at that spot. Query,
Had the rebound of the shot from the bone struck the eye so sharply as to cause
this? That was my impression after careful examination.

"In contrast to these cases stands the following, recently seen by me in con-
sultation with Dr. Cape. A young nobleman, who had always suffered from
weak sight, received an accidental blow upon the right eye. Two days after-
wards it was found that he could only distinguish light from darkness with that
eye. The question arose. Was this loss of sight the result of the blow or not?
The ophthalmoscope decided in the negative, for the eye appeared perfectly
healthy, and there was a total absence of effusion. Dr. Cape agreed with me
in the opinion that the blindness following the blow was merely a coincidence,
and that pain in the head and other symptoms indicated that the brain was the
seat of mischief. In this view we have been confirmed by the improvement
which has taken place under depletion, blistering the nape of the neck, and a
course of mercury; the sight is steadily returning." — Lancet, June 14, 1862.

43. Atropia Paper. — Mr. Streatfield recommends {London Royal Ophthal-
mic Hospital Reports, Jan. 1862) as a convenient substitute for the solution of
atropia, a green-coloured tissue paper imbued with the solution of atropia and dried.
Such paper is more readily carried about in the pocket than a bottle of the solution.
"The little piece of paper to be used, one-fifth of an inch square," he says, "is
taken up on the tip of the forefinger, previously damped, and the patient's lower
lid being drawn down, he is told to look upwards and the scrap of paper is put
on the sclerotic conjunctiva below the cornea almost without the knowledge of
the patient; the lid is then let go, and the piece of paper is left between the
ocular and palpebral conjunctivae ; a handkerchief is then tied over the eye that

556

Progress of the Medical Sciences.

[Oct.

the lids may be kept closed for awhile." Mr. S. says that this acts quite as well
as the common solution.

44. On the Advantages of having Eye-instruments Gilt {especially some of
those employed in Iris-operations), with a note concerning Non-metallic Instrv^
ments. By Mr. Streatfield. — " Occasionally we may see an instrument used
in ophthalmic surgery that has been gilt, but this distinction seems to have been
without any other purpose than that of ornament. No one eye instrument, that
I know of, is always gilt,' nor is any one class of instruments commonly thus
distinguished, but there are practical advantages in having a gold surface, to
some of them at least, that I have learned not to neglect. The first instrument
I have had gilt was my spatula-hook, for in the operation of corelysis, when the
instrument, passed behind the pupil, is in apposition with the lens, it is not easy
to tell, and it is so much the more important to know the exact position of the
instrument and the direction it is made to take.^ I found, as I expected, that
in using this, instrument it enabled me to see better what I did in all that I had
to perform. Then I had an iris-hook gilt, and, for the operation in which it was
employed, I again found the advantage of the yellow metal, and now I intend
to have the canula-forceps and scissors and other iris instruments coated in the
same manner. I am inclined to think that at least all instruments used for ope-
rating on parts within the eye should be gilt — the cutting instruments may be
an exception — but of those that can be gilt the lighter colour will make them
much to be preferred to the dark polished surface of steel. In an operation,
there are two reasons why a steel instrument is not easily seen in the eye — it is
so dark that, in the anterior chamber, it probably does not contrast well with
the colour of the iris, and it has so smooth a polish that, in the deeper parts of
the eye, it does not generally reflect enough light. In the aqueous chambers
its highly polished surface reflects the light very strongly from some one part or
another of the instrument (it is not always easy to tell whence it comes), or the
instrument cannot be well seen because the light is hardly at all reflected from
it. A surface of gold is perfect with a much less degree of polish, for it will
not rust, which is another especial advantage for eye instruments, because of
the tears and other watery fluids with which they are brought into contact ; for
this reason, eye instruments generally, being so small, would be kept in better
order if they were gilt. Steel, even with care, will rust if there is any want of
smoothness on its surface. Dull gold, on an instrument of polished steel, will
show light whichever way the instrument is held.

" I do not know why any small blunt instruments which we employ should be
always of steel or any other metal, and therefore, wishing to have a spatula-hook
to be as conspicuous as possible in contrast with the iris and its brown adhesions,
I have had one made of ivory, and although it is so very small it is tough, and
very little strength is required in it, as. for other reasons, no force may be used
in the detachment of iris adhesions. In corelysis lately, I have employed this
instrument, and have found it practically answer my purpose better than any
other that I have of metal."

MIDWIFERY.

45. Turning in Cases of Disproportion between the Foetal Head and the
Pelvis of the Mother. — Dr. M'Cltntock read before the Obstetrical Society of
London (July 2, 1862), a valuable practical paper on this subject. This paper
embodied the results of seventeen cases which came under the author's care in

' Unless it is the director for the operation of " slitting up" the canaliculus ; the
probes that accompany it should rather be gilt, for a practical purpose, because,
left in the nasal duct, they often become blackened.

2 See vol. ii. p. 324.

1862.]

Midwifery.

55T

the wards of the Dublin Lying-in Hospital. In each of them turning had been
performed, at various periods after the commencement of labour, on account of
disproportion between the head and pelvis. In none of these cases was there
any considerable deformity of the pelvis, though the obstetric histories of the
women clearly showed that there must have been some slight narrowing of the
superior strait. More or less difficulty was experienced in every instance in
bringing down the head into the pelvis, and twice craniotomy had to be resorted
to. On one occasion the parietal bone (that next the sacrum) was fractured in
pulling the head through the brim of the pelvis. With one exception, all the
patients were deeply chloroformed before the operation of version was under-
taken. Nine of the children — viz., four boys and five girls — survived birth,
though all were alive when the operation was commenced. Of the eight children
dead born, five were boys and three girls. The heart continued to pulsate for
several minutes after birth in some of the children recorded as " dead born,"
Dr. M'Clintock not considering a child as saved by an obstetric operation, nor
recording it amongst the " live births," unless respiration be fully established.
All the women recovered satisfactorily but one, who died of puerperal fever, of
which some cases had occurred at the time in the hospital. In reviewing these
cases. Dr. M'Clintock expressed his opinion that the operation was not so
favourable for the child as some of its advocates had supposed, and that it was
only when the amount of pelvic narrowing was very slight that we could reckon
with any degree of certainty upon saving the foetus. He would not, therefore, re-
commend the operation in preference to the induction of premature labour in cases
where an option was left us, and a decided contraction of the pelvis was known to
exist. At the same time, that it was a valuable resource in cases of this class
which may have reached the full period of^egnancy, he proved by the fact,
that of eighteen boys born to the above patlRits, and delivered by other modes
than turning, only two were alive at birth ; whereas four out of the nine deliv-
ered by turning survived their births. Looking to the interests of the mother,
the author of the paper considered that the operation of turning in the particular
class of cases under notice had stronger claims ; for not only did it abridge the
labour process, which in itself was no small advantage, but it averted the possi-
ble contingencies of craniotomy, high forceps operation, or even of rupture of
the uterus. Its great mechanical advantage. Dr. M'Clintock thought, was due,
not to the position of the head nor its greater compressibility when coming
through the pelvis with the base foremost, but to the unlimited amount of force
which we can bring to the aid of the uterus by traction on the body of the
child.— ifed. Times and Qaz., Aug. 23, 1862.

46. Inversion of the Uterus occurring Spontaneously Eighty Hours after
Delivery. — Some obstetricians believe that inversion of the uterus is always the
result of some cause over which the attendant has control, and that in most
cases it is caused by undue traction on the cord. Dr. Radford, however, has
clearly established that it may occur spontaneously without any fault of the
midwife's, and that it may occur not only immediately after delivery, but also
after an interval of some days. Mr. Charles Cowan relates [Edinburgh Medi-
cal Journal, June, 1862) a case which is conclusive as to this point.

The subject of it was a lady, forty years of age, always in the enjoyment of
good health, who was delivered with the forceps, after a pretty smart labour of
twenty-four hours' duration, of her first child, a strong healthy boy, at 4 A. M.,
on Thursday the 15th November, 1861. The placenta was found in the vagina,
ten minutes afterwards, and removed. In about half an hour there was slight
hemorrhage, which was easily restrained by the application of cold to the pubic
region, which caused the uterus to contract firmly : a little brandy was likewise
administered, as I attributed the hemorrhage to the weak state of the patient,
occasioned by the protracted labour, and by my efforts to accomplish delivery
with the forceps, which occupied me more than half an hour.

I remained with her an hour longer; and to satisfy myself that all was right
I removed the bandage, and, on manipulating the abdomen, 1 discovered the
uterus firmly contracted, about the size of a cricket ball, in its normal situation.

558

Progress of the Medical Sciences.

[Oct.

The bandage having been replaced I administered a dose of morphia, and took
my leave.

For the first three days after her confinement, we have the patient giving the
most satisfactory evidence of speedily attaining convalescence. The pulse be-
comes natural; the appetite returns; the secretions are normal; the breasts are
distended with milk, and the mother rejoices in the prospect of being able to
nurse her child. Her sister finding her so well on the Saturday afternoon (two
days and a half after delivery), returns home, and on the Sunday the patient
expresses a wish to get up. What could be more gratifying than this ? What
could more strongly indicate a rapid restoration to health ? So far it appears
that all is well ; but on Sunday at mid-day, about eighty hours after delivery, a
change takes place. Eager to test her strength she leaps out of bed, comes to
the ground with some degree of violence, staggers to the fireplace, and falls into
a chair in a state of syncope.

There had undoubtedly been mischief, and that of no light character, for
from this moment a train of symptoms of the most alarming description followed,
becoming hourly more and more serious until the cause was discovered in the
inversion of the uterus, and replacement was accomplished. She now again
began to show some slight signs of amendment, and we cannot but conclude that
the inversion was occasioned by the hurried leap out of bed, especially as the
unfavourable symptoms presented themselves then for the first time ; and we
have further proof of this in the amelioration of these symptoms, commencing
almost as soon as the displacement of the uterus was reduced.

47. Vessels concerned -in the Production of Phlegmasia Dolens. — Dr. Tilbury
Fox read a paper (June 4, 1862) on this subject before the Obstetrical Society
of London. The author first refdRed to Dr. Mackenzie's experiments as insuf-
ficient to determine the question of the production of phlegmasia dolens, and
proceeded to argue that venous obstruction is followed by oedema only; that the
action must be the same, whether the obstruction be produced locally or indi-
rectly through a vitiated blood condition. If any diff"erence in the two cases
existed, the changes over and above oedema, which characterize the lesion as
phlegmasia dolens, must be ascribed to the action of the blood state (which is
absent in the locally produced disease) upon the general textures of the limb.
If this view be adopted, the influence of the veins is nil, and we must look for
the explanation in a special action carried on between the blood and the tissues.
That the clinical history forbids the acceptance of such a doctrine, inasmuch as
the very conditions (viz., blood-vitiation tending to produce "phlebitis") which
are regarded as the cause of phlegmasia dolens very frequently exist, and yet
are very rarely followed by white leg — for example, in the various blood-poison-
ings unconnected with the parturient condition. That if produced under the
circumstances mentioned, the disease ought not to be so frequently unilateral,
nor confined to the lower limbs. That the occurrence of white leg in cases of
cancer, phthisis, pressure, etc., could not be explained hereby. That the death-
rate of phlegmasia dolens forbade the same interpretation of the phenomena.
That in the experiments of the injection of lactic acid into the blood by Dr.
Mackenzie, there was no evidence to show that in the dogs operated upon any-
thing but oedema resulted. That the existence of phlebitis, except as the rarest
feature, is fallacious in cases of venous disease. Attention was then drawn to
the distinction between the coincidences and the essentials of phlegmasia dolens,
as in the case of puerperal fever complicated by the latter. For example, take
away from the general total of such a case the proper puerperal fever symptoms,
and the phlegmasia dolens remains in perfect integrity; per contra, take away
the hot, white, tense, elastic swelling, and the puerperal fever remains in its
entirety. In the combination, however, the pathological changes normal to
phlegmasia dolens may be modified by the tissue actions (abscess, etc.), which
are the consequences of the existence of a virus in the blood; in uncomplicated
phlegmasia dolens, the tissues are passive, so to speak. The succeeding remarks
went to show that the theory propounded by White was correct with regard to
the nature, though not as to the cause, of phlegmasia dolens ; that in the natural
condition a large quantity of lymph travels from the limbs towards the thoracic

1862.]

Hygie ne.

559

duct, and when this current is impeded markedly white leg resulted. The case
of the absorption of a poison into the cellular tissue (which, according to some,
controverts White's opinion) was examined, and it appeared that this might or
might not be followed by phlegmasia dolens, according as the obstruction in the
lymphatics affected the main current or merely some minor channels (the latter
being the rule) ; the swelling being modified in severe cases, as before observed,
by the relative action of the septic blood state and tissues. Cases were quoted
to prove that lymphatic obstruction is sufficient, and alone necessary, to give
rise to phlegmasia dolens. The paper concluded with the following summary :
1. Phlegmasia dolens is a local disease. 2. No general symptoms need be pre-
sent (implying absence of blood-poison). 3. Phlebitis, however produced, can-
not give rise to phlegmasia dolens, but oedema only. 4. Phlegmasia dolens may
occur in, but forms no necessary part of, blood-poisoning (such as tends to phle-
bitis), but is modified thereby frequently ; and any tissue conditions over and
beyond the presence of fibrinous serosity, and the consequent hypertrophous
state of the areolar tissue, are in nowise essential components of phlegmasia
dolens, but common alike to very many different "blood" diseases. 5. Obstruc-
tion to the main lymphatic channels alone is capable of giving rise to white leg,
and acts by preventing the removal of the lymph from the affected limb. 6.
The obstruction may be the result of {a) extrinsic pressure; (5) thrombosis due
to sudden (compensatory) absorption of vitiated fluid after sudden loss of any
kind; (c) inflammatory changes in the vessels themselves (rare). 7. The effect
of the action of venous obstruction upon the phlegmasia dolens is an intensifi-
cation of the general swelling, and the presence of oedema during the subsidence
of the enlargement of the limb. Lastly, a frequent, but unrecognized, source
of blood-vitiation was alluded to, namely, in cases where large tracts of cellular
tissue were diseased — as in erysipelas, sloughing, cancerous, phthisical, and
dysenteric ulcerations, and the like — the lymphatics, charged with e^ete matter,
and an excessive number of imperfectly-developed pale cells, formed in their
glandular part, pourad their contents into the venous system from the thoracic
duct; and this mighf be a cause of thrombosis at the right side of the heart and
in the vessels leading to the lung. — Med. Times and Gaz., July 12, 1862.

HYGIENE.

48. Influence of Railway Travelling on Public Health. — The Nos. of the
Lancet for Jan. 4, 11, 18, and 25, Feb. 1 and 8, and March 8, contain an elabo-
rate report of a commission appointed to investigate this subject. It will be
seen from the following concluding paragraphs that they consider its influence
to be unfavourable : —

" The efficiency of the rapid concussions incidental to railway travelling in
developing or aggravating epilepsy, chronic spasm, cerebral softening, and spinal
softening, has been studied, not by the light of vague conjecture, but upon the
authority of strictly-observed cases in the practice of men such as Sir Ranald
Martin, Dr. Brown-Sequard, Dr. Eadcliffe, and others. The particular influence
of cold and draught has been brought out prominently by Dr. Williams ; while this
has been placed in necessary juxtaposition with the exact inquiries as to venti-
lation and relative purity of the air in railway carriages by Dr. Angus Smith.
The mischief following from undue retention of the secretions is sufficiently and
practically illustrated in the case by Mr. Hilton. The nature of the impressions
so well studied by Sir David Brewster has been traced to its pathological con-
sequences by Mr. White Cooper. Dr. Fuller's ingenious observations on the
part played by the auditory nerve in conveying to the brain strong and inces-
santly repeated impressions of sound, are of a practical and suggestive character.
This is, no doubt, one cause of the peculiar effects of continued railway travel-
ling, which had not been well known, and of which the mischief is preventable.
The almost certainty with which a long railway journey will, in some pregnant

560

Progress of the Medical Sciences.

[Oct.

women, produce abortion, has been well illustrated in the communications by
Dr. Meadows and Dr. Graily Hewitt. The acceleration of the pulse in railway
travelling is one of the indications of the extent to which this form of passive
exercise taxes the system ; but all physiological deductions require to be received
with great reservation, as the disturbing elements are so many and various.

" There are only two classes of persons especially likely to be injuriously
affected by moderate railway journeys, even though frequent: they are persons
advanced in life and of weakened power, and those who are subject to the special
diseases which have already been studied in this relation. The actual exertion,
the excitement, the mental strain, the peculiar influences of the motion of a
railway carriage, indicate its dangers to those first mentioned. These constitute
a small minority. But there are a number of persons who, although not far ad-
vanced in age, are yet the subjects of various conditions of ill-health depending
on insidious degenerative disease of the brain and heart. The season-ticket
holders of the railways are in large numbers men who have passed the best years
of their life in hard and exhausting employment of mind and body. They are
the successful merchants ; the senior partners of flourishing firms, which they
have built up by a life of labour ; half-retired tradesmen ; half-invalid bankers,
et id genus omne. We can now see that it is by the injuries which have resulted
to these men from their constant travelling to and from town that an impression
has become current as to certain mischiefs which habitual travelling inflicts.
When it is stated that such a banker, who comes up fifty miles three or four
times a week, has to lie down half an hour before he can sign a check ; that such
a well-known chemist has suffered from symptoms of brain excitement since he
bought his new house by the sea, and travelled daily to Loudon ; or that a cer-
tain barrister has found himself obliged to pay for his journey by epileptic seizures,
the alarm soon extends beyond reasonable limits. But few men can endure
without suffering to travel fifty or a hundred miles daily to their business for
any length of time. The influence of the journey itself is heightened by many
accessory conditions to which we have adverted ; and the^resent construction
of the rails and carriages is such as to deprive the traveller of all those mitiga-
tions by which his discomfort might be diminished and his health safe guarded.

" Amongst the unprecedented collection of cases brought under our notice
during this inquiry, there have been recorded several of serious mischief, and
even death, from persons in ill health hurrying to catch trains and sitting down,
heated and breathless, in the draught caused by the moving of the train which
they have just managed to be in time for. It is almost exclusively at large
termini that these cases have occurred, and that the cause of them obtains. Now,
this rushing in at the last moment, we are informed, is becoming more frequent ;
and consideration of the condition in life of those who constitute the majority of
season-ticket holders, would indicate how this evil arises. We believe it would
be advantageous to public health and safety, however harsh it may at first ap-
pear, that the doors at termini should be closed five minutes previous to the de-
parture of each train, so that sufficient time should be allowed for passengers
to quietly settle themselves, and also for the ofiicials, who are often (as one of
them graphically expressed it) ' torn to pieces' just at the last moment. It is
well known that the difficulties with luggage, which this arrangement would
obviate, are frequently causes of delay in starting trains. Then there is high
speed to make up lost time, or want of punctuality, both of them fraught with
danger to passengers.

" It has been shown that the injurious effects which habitual railway travel-
ling produces on some who escape such influences when only taking occasional
journeys are very marked. In such persons, heedless continuance comes to be
a cause of disease. In some, there have been no previous symptoms that they
could recognize, or such as would have deterred them from undertaking the
daily journey ; and thus the season ticket is taken, and has soon to be disused.
In all cases the evidence points to the conclusion that the injurious influence
slowly and gradually increases whilst the cause remains — that tolerance is not
established by persistence.

" It is too much the custom, when adopting a country residence on a railway
line, to make no arrangements of business according to the diminished time for

1862.]

Medical Jurisprudence and Toxicology.

561

work which the daily interval between the morning and evening trains allows.
Hence that hurry, anxiety, and working of the brain at high pressure, which, of
all things, tends to develop in susceptible persons such injurious effects on
health as habitual railway travellers often experience. The remedy for this is
obvious : ' Cut your coat according to your cloth' — ' Mene tenus propria vive' —
' Selon le pain il faut le couteau,' are saws proved to be wise. But we believe
that no person is justified in undertaking a series of continuous journeys by rail
under the conditions alluded to (if under any circumstances), without previously
consulting his medical attendant as to their probable effect on his health, the
precautions he should adopt, and the warning symptoms which he may not safely
disregard."

MEDICAL JURISPEUDENCE AND TOXICOLOGY.

49. Poisoning with Upas TieuU. — Some time since a gentleman of Berlin
received from Java some of the arrow-poison, upas tieute, and fearlessly subjected
himself to the action of the poison. He took three grains of the substance, which
he found to have a very bitter and slightly saline taste. After having swallowed it,
the Doctor felt more cheerful, and a headache which he had had passed off ; on the
other hand, a feeling of heaviness in the stomach supervened. He soon afterwards
left his rooms and went out ; and the first sign of the action of the poison having
begun, was that on turning round the corner of a street and feeling a strong
wind, he perceived a sort of stretching all along the spine. This was half an
hour after he had taken the poison. An hour afterwards, on being about to
take a cup of coffee, he suddenly felt a violent concussion of the whole body,
succeeded by powerful stretchings of all the extremities ; at the same time the
head was drawn backwards. He endeavoured to speak, but could not open his
mouth. This paroxysm soon ceased, but others followed rapidly, either spon-
taneously or after the slightest stimulus. Consciousness was not in the least
disturbed. The fits were not painful, the respiration was not impeded, and the
muscles remained quite flaccid after the fits. Swallowing was difficult, and the
patient felt very weak. He then desired to be brought to the Charite Hospital,
and on being carried down-stairs violent spasms came on ; while in the cab
which took him to the hospital, he was quite free from them. He was transferred
to the cliuique of Professor Frerichs, where ipecacuanha and tartar emetic were
at once given, as it was supposed that part of the poison might still be in the
stomach. Copious vomiting ensued, accompanied by tetanic convulsions, spasm
of the glottis and dyspnoea; but the latter ceased with the vomiting. Further
convulsive fits followed either spontaneously or on touching the patient's body
• or the bed, or on suddenly directing a light to the eye. The pulse was 72, and
there were no other morbid symptoms. The patient now took ten drops of
laudanum every quarter of an hour, and after three such doses, he took fifteen
drops every half hour. Having thus altogether taken sixty drops he fell asleep.
He perspired freely, and was repeatedly awakened by tension and convulsions
of the muscles of the neck and the back ; but on taking a few more drops, he
soon fell asleep again, and remained so for twelve hours. On awakening the
next morning he felt exceedingly weak ; there was still some stretching in the
muscles of the left side of the neck, but no spasms. The pulse was at 66.
Swallowing was still impeded, and the urine passed ofi" with difficulty. This
was found to contain strychnia. The laudanum was then discontinued, and the
patient merely took wine and easily digestible food. On the third day he was
able to leave his bed, and on the sixth his health was quite re-established.

The poison was subjected to examination in the chemical laboratory connected
with the hospital. It was contained in a piece of bamboo-cane, and consisted
of a coarse-grained reddish-brown substance, in which several shining cystals
were seen. On putting some of it under the microscope, amorphous grains
and small tetrahedral crystals were discovered. A small trace of this substance
gave a strong reaction of strychnia, and it was found that in a hundred parts
No. LXXXYIII^OcT. 1862. 36

562

Progress op the Medical Sciences. [Oct.

of upas, sixty-two parts of pure stryclinia were contained, so that the three
grains of upas taken by the Doctor were equivalent to about a grain and three-
quarters of strychnia. Frogs and a dog, to which some of the poison was given,
died in a short time. If woorara had been at hand, it would probably have
been administered to the patient, although, on the whole. Professor Frerichs is
disinclined to try it on patients, as we have until now no certain data as to the
doses in which this powerful drug should be given. The effects of opium were
in this case certainly very satisfactory. — Med. Times and Gaz., Aug. 23, 1862.

50. Strychnia Poisoning. — M. Duriau publishes an article in which he com-
ments upon the needless difficulties which have been unfortunately thrown
around the subject of strychnia poisoning. He considers that the symptoms
produced by the latter are perfectly distinct from any other morbid phenomena,
and that the discussions raised upon Palmer's trial, as to whether the symptoms
observed might not have been caused by tetanus, hysteria, or the like, were
most unnecessary. He illustrates the characters of the strychnia affection by
a case which he relates : the following is a resume of the principal facts. The
patient was a woman aged 28, who swallowed one-sixth grain of strychnia ; in ten
minutes the convulsions began ; they lasted two or three minutes each, and were
separated by intervals of one or two minutes, and always ended in a muscular
rigidity of all the body, and especially of the inferior extremities.' In these
different crises she seemed to desire sometimes to get out of bed, but tetanic
spasm always hindered her from doing so. Each access of spasm commenced
by a slight trembling, analogous to the shivering of fever, which communicating
itself by degrees from the extremities to the trunk, was replaced by clonic con-
vulsions, and then by the rigidity already mentioned. Swallowing was impos-
sible, liquid introduced into the throat nearly caused suffocation. Finally, the
temperature of the body was elevated, and there was a copious sweat. This
condition persisted for sixty-two hours, after which time the patient returned
gradually to consciousness. From this time the chief symptom was a burning
sensation in the epigastrium and the pharynx, and a complete intolerance of the
stomach for all kinds of liquid or solid food ; this lasted for not less than six
weeks. M. Duriau points out that this case, and one reported recently by M.
Dauvin, show perfectly the entire distinction that there is between the symptoms
of tetanus and strychnia. Besides the obvious difference between the nervous
symptoms of the two affections, M. Duriau directs attention to the stomach dis-
turbance which was present. He declares that this is not an uncommon pheno-
menon, and that in fact an inflammation of the gastric mucous membrane is not
unfrequently produced by strychnia, and leaves its marks after death. M.
Dariau considers that the use of leeches and of general bleeding is justified in
cases of strychnia poisoning where inflammatory symptoms are present, and he
justifies himself by quoting Yierordt's experiments, in which it was found that
animals who had been bled resisted longer the action of strychnia, and died less
quickly than those which had not been bled. In conclusion, M. Duriau announces
these propositions : —

1. In strychnia poisoning anatomical lesions of the stomach are not rare. 2.
Without offering a character which is specific and constant, these lesions are
of an inflammatory nature. 3. They are manifestly produced by the action of
the poison upon the gastric mucous membrane. 4. They ought never to be
neglected in a judicial investigation; for, joined to the symptoms observed
during life, they will sometimes lead to a suspicion of poisoning.

M. Duriau believes, it may be remarked, that the processes of Staas and
Eodgers have rendered the chemical detection of the smallest quantities of
strychnia certain. — Dub. Med. Press, Aug. 13, from Annal. d' Hygiene and Lon-
don Med. Review.

1862.]

563

AMERICAN INTELLIGENCE.

DOMESTIC SUMMAEY.

Injury of the Arm common to Children of from one to four years of age. —
[Dr. R. M. Hodges relates [Boston Med. and Surg. Journ., Sept. 18tli, 1862)
three cases of an accident often observed in children, and the exact nature of
which has probably frequently puzzled the practitioner, in consequence of the
impossibility of persuading the little patient to submit to a careful examination,
and the suddenness with which the symptoms often disappear.]

Feb. 2, 1862. A nurse, holding the hand of a little girl twenty-eight months
old, in a moment of impatience gave it a sudden twitch. The child immediately
cried out, would not allow herself to be touched, and held her arm motionless.
Her mother, however, placed it in a sling, and three hours after the accident the
limb was found in the following condition, viz., bent at an obtuse angle and rest-
ing against the body, the forearm much pronated. There was no apparent swell-
ing or deformity, but the slightest motion was extremely painful, and .the little
patient was unable or unwilling to hold anything in her hand. On manipulating
the limb there seemed to be some impediment in its natural movements, and in
attempts to produce certain of these a feeling suggesting crepitus was detected,
but before either the seat of this, or the actual diminution of mobility could be
determined by examination, the abnormal condition of things vanished, the child
ceased to cry, took her playthings in her hand, and the limb was evidently once
more in its natural condition.

Feb. 7, 1862. A little girl, thirty months old, fell whilst walking across the
parlour floor, her mother holding her by the hand. When s«en, her limb pre-
sented a condition precisely analogous to that described in the preceding case —
there was the same pronated and semi-flexed position, the child was unwilling
to use it, and cried the moment it was touched. Before I could ascertain what
the exact injury was, manipulation had produced the obscure crepitus, or some-
thing which seemed like it, the pain and immobility instantly disappeared, the
child readily took its playthings, and with the exception of a little fright, was
herself again.

These two cases occurred in the course of the same week, and were the first
and only ones of the kind which had ever fallen under my observation. I had
■ considered them both as instances of incomplete dislocation of the head of the
radius forward. This accident, or, at all events, this phase of it, is not described
in the common works on surgery, although a thesis in French, one or two arti-
cles in journals, and a description by two or three French writers may be found,
in. all of which it has been looked upon as some form of dislocation of the upper
extremity of the radius. M. Goyrand, of Aix, however, who has written several
articles on the subject, takes an entirely different view of the matter. In a
paper recently presented to the Surgical Society of Paris [L' Union Medicaid,
Nov. 23, 1861), and which has fallen under my notice since the occurrence of
the two cases above described, he sums up the symptoms of this accident so
accurately that I venture to quote his description, behoving that, in the absence
of any readily accessible account of the injury, its recapitulation, with an ab-
stract of some of his remarks, will not be altogether amiss.

A child, from one to three or four years of age, is saved from a threatened
fall by being suddenly caught by the wrist, or it is lifted over a gutter, or made
to step up by a violent pull of the pronated hand. At the moment of the strain,
the person holding the hand notices a slight snap or shock. The child cries out
and continues to complain ; the limb hangs motionless by the side, a little in
front, with the elbow partly bent and the hand pronated. Any attempt to supi-

564

American Intelligence.

[Oct.

nate the hand increases the cries, the rotation outwards is brought up by a me-
chanical obstacle, and if this is not overcome, as soon as the hand is let go it
returns to its pronated position. This symptom is pathognomonic. If the
resistance is overcome, a snap is heard or a slight jar is felt, pain ceases, motion
is restored, and no trace of the accident remains. If nothing is done by the
surgeon, after a certain period which varies from a few hours to several days,
the limb spontaneously resumes its natural condition, ordinarily during sleep.
If any length of time elapses prior to the reduction, either by the surgeon or by
the efforts of nature, the hand becomes adducted, and there appears on the dor-
sal surface of the wrist and the neighbouring parts of the forearm a painful
swelling similar to that accompanying fractures, dislocations, or sprains.

M. Goyrand had always considered the lesion in these cases as a partial dislo-
cation of the radius at the elbow, but so slight as to give no appreciable de-
formity of the articulation. In 1857, a case occurred which revealed to him
what he now conceives to be the true nature of the injury, viz., a displacement
of the inter-articular fibro-cartilage of the wrist in front of the carpal extremity
of the ulna. In complete pronation, the inferior articulating surface of the head
of the ulna is exposed behind the corresponding border of the fibro-cartilage by
more than three-quarters the thickness of the bone, and hence, in a forced rota-
tion of the radius in the direction of pronation, it is conceivable that the fibro-
cartilage may easily be carried in front of the head of the ulna. This displacement
occurs only in childhood, as it can only be produced by great violence ; in adults,
forced pronation is prevented by antagonistic muscles brought into action as
soon as pronation becomes painful. This cannot be done by a child. The vary-
ing size of the head of the ulna explains why some children, exposed to a cause
capable of producing this displacement of the fibro-cartilage, escape the accident.

The following cases are submitted in justification of this diagnosis, and as
illustrating the symptoms developed by the accident.

Obs. I. Mary J., one year old, just beginning to walk. July 6, 1861, whilst
walking, being held by the right hand, her brother, seven or eight years old, fell
heavily against her. The nurse, squeezing its hand, pulled the child quickly
towards her, and in doing so felt something " give way" in the little arm. The
child immediately began to cry; the limb was held motionless, resting against
the body, carried a little in front, and with the forearm pronated. No deformity
about the wrist or elbow. Motion or pressure about the elbow causes no pain,
but pressure on the back of the wrist makes the child cry out. On supinating
the hand, the movement was felt to bring up against some resistance, the child
cried louder, and the hand when released assumed its previous pronated position.

The arm being held by the mother, M. Goyrand seized the hand in his right,
with the thumb on the lower end of the radius and the forefinger on the head of
the ulna; with his left hand he gently supinated that of the child. Before
supination was completely effected, the finger resting on the end of the ulna felt
a slight shock ; instantly the resistance to supination was overcome and reduc-
tion accomplished.

Two minutes afterwards the child took in its injured hand a bracelet held out
to it by its mother. The mobility was completely regained, and all uneasiness
and pain gone.

Obs. II. Margaret D., thirty-five months old, held by the left hand, made a
false step, and from the sudden jerk which the hand in a state of pronation
received there resulted the injury which M. Goyrand makes the subject of his
paper. One of his pupils, a physician in the town where the child's parents
reside, being called to the case immediately on its occurrence, recognized the
injury and supposed that he had reduced it. The symptoms of the displacement
did not, however, disappear, for on the following day the limb was immovable
and in a pronated position. M. Goyrand saw the child fifty hours after the
accident and noted the following symptoms, viz., those which are mentioned in
the previous observation, and in addition, on the dorsal surface of the wrist, a
swelling extending to the neighbouring parts of the forearm and hand ; this was
extremely tender to the touch, especially at a point corresponding to the articu-
lar interspace of the wrist. There was a slight inclination of the hand to the
ulnar side of the limb. In reducing the displacement, the finger which rested

1862.]

Domestic Summary.

565

on the carpal extremity of the ulna felt, distinctly, when the hand was brought
into supination, a crepitus precisely like that in a case of fracture. Before
supination was completely produced the sensation ceased, opposition to supina-
tion was overcome, and the reduction was accomplished. Thirty-six hours after-
wards no traces of the accident remained.

In both these children the displacement happened again in the same arm. In
other cases which have been noticed, the two limbs have been successively the
subject of the accident, one after the other.

In the discussion which ensued upon the presentation of this paper, it appears
that MM. Guersent, Marjolin, Giraldes, and Velpeau were at a loss to accept
M. Goyrand's explanation. M. Guersent believed that the cases in question
comprised a variety of lesions with certain identical symptoms. M. Marjolin
thought that in many of these cases he had seen a deformity about the elbow.
MM. Giraldes and Yelpeau thought that a dislocation of the fibro-cartilage
could not take place without a lesion of the serous membrane of the articular
cavity, after which consecutive symptoms should be developed, no matter how
simple the reduction might be. Are we then to accept this explanation of the
phenomena presented by this injury?

Although M. Goyrand fortifies his opinion by the results of experiments on
the dead subject, he admits that the fibro-cartilage will not remain displaced
unless the hand is held up and in forced supination. In two attempts which I
have made upon very young subjects, I have not been able to produce this dis-
location, nor when the joint was opened have I been able to force the fibro-carti-
lage into the position which M. Goyrand assumes that it takes, without tearing
it from its attachments. Any one who will examine for himself the very limited
range of displacement of which this cartilage is capable, except by the use of
violence which must determine more marked symptoms than ever follow this
accident, will be convinced of the error of M. Goyrand's views. Although no
two writers agree upon the precise nature of the injury, all of them, with the
exception of M. Goyrand, locate it at the elbow. This diversity of opinion is
accounted for by the fact, that before its seat can well be ascertained the symp-
toms disappear with the very first exploratory manipulations. It would seem,
from the weight of testimony and from my own experience, that without attempt-
ing to account for this somewhat peculiar, and, as I judge, not unfrequent acci-
dent, by any ingenious theory or complicated displacement, a satisfactory
explanation of its pathology is to be found in the partial luxation of the head
of the radius, which, either in one direction or another, is accepted as its ration-
ale by Duverney, Bouley, Monteggia, Martin, and Fougeu d'Etampes. This
view finds support in the position assumed by the arm, and the manner in which
the symptoms of the injury disappear. Eotation and flexion (which, of course,
if carried through the whole range, implies extension) are the first motions which
every surgeon gives to an arm when he examines it for a suspected fracture or
dislocation; and in a child, where this bone was but partially out of place, might
well be adequate to the reduction, even when practised gently and but a single
time. An adult would perhaps unwittingly or of his own accord reduce a dis-
location of this slight degree, when in a child, from pain and fear, it might
remain persistent till surgical aid arrives. In the absence of this, we are told
that in the course of time spontaneous cure is effected. Would this occur if
there were so serious a displacement as that of the interarticular fibro-cartilage
of the wrist? It appears then that the following opinions present themselves : — •

1st. That of M. Guersent, who conceives that the cases in question comprise
a variety cf lesions with certain identical s.ymptoms. 2d. That of a number of
writers, who attribute the symptoms to a partial dislocation of the head of the
radius in one direction or another. 3d. That of M. Goyrand, which has been
detailed at length.

The cases present too striking a similarity to admit of the acceptance of the
first of these, and of the third we have already given our opinion.

The second, therefore, seems to merit the most favourable verdict, and the
latitude which it permits is, in the present state of our knowledge, no more per-
haps than it is discretionary to allow.

Since writing the above, a third case has fallen under my notice. A child ten

566

American Intelligence.

[Oct.

montlis old was brought to the dispensary, June 24th, 1862, with her hand in a
sling-, having received an injury to the elbow the afternoon previous, by being
lifted up with a jerk by the wrists whilst lying on its back, in which position its
grandmother had been putting on a diaper. The symptoms of injury, to wit,
crying and inability to use the arm, ensued at once. On examination the fol-
lowing morning, the characteristic position, semiflexion and pronation, and pain
on motion, with the absence of deformity or swelling, led me to suspect the
nature of the accident, and I was able to satisfy myself that the seat of injury
was not at the wrist. The opposition to rotation was evidently at the elbow,
and a single sensation of crepitus was felt at this point, but on manipulating to
detect, if possible, the condition of the parts, the resistance to supination was
unexpectedly overcome and the normal state of things assumed, before I had
ascertained what the precise derangement was which stood in the way of free
motion. The experience of this case confirms me in my opinion of the errone-
ousness of M. Goyrand's views, at least in their general application.

Acute Chorea Treated with Whishey. — Dr. Clark related to the New York
Medical and Surgical Society a case of acute chorea which was interesting from
the illustration it afforded of the good efiects of what he believed to be an en-
tirely novel treatment in that disease. A girl, sixteen years of age, was admitted
recently to Belle vue Hospital suffering from an aggravated form of' chorea of
four weeks' duration. The convulsive movements were so violent and incessant
that she had not slept for four or five nights previous to the admission. Dr.
Clark having observed the sedative effects of whiskey administered in intoxicat-
ing doses in some cases of idiopathic tetanus, determined to try the same remedy
in this case. He directed that half an ounce of whiskey should be given to the
patient every half hour until intoxication was produced if necessary and sleep
followed. After the third dose the girl slept half an hour, after the fourth dose
she slept three hours, and from this time she slept well with doses repeated at
longer intervals, and subsequently with the use of tonics has improved rapidly.
There were no symptoms of heart disease in this case, and there had been no
previous rheumatism of the joints. — Am. Med. Times, Aug. 2, 1862.

The Liver in Cholera Infantum. — ^Dr. J. Lewis Smith, Curator of the Nur-
sery and Child's Hospital, has published [American Medical Times, Sept. 20th,
1862) some interesting investigations which confirm the prevalent belief that
the liver plays an insignificant part in the pathology of the summer complaint
of children. "The green stools," he justly remarks, "which have long been
referred to the biliary secretion, must be mainly due to causes operating in the
intestines, for I have repeatedly noticed that the green colour does not appear
till we reach the lower part of the jejunum, or upper part of the ileum. Exa-
mined under the microscope the green matter is found to be in little fragments
or masses, as if produced in the crypts of the intestines."

Dr. S. gives the result of the post-mortem appearance of the liver in thirty-
seven cases. No evidence is afforded by these of any congestion, or torpidity,
or hyperactivity, or perverted secretion, or abnormal size of the liver. "In
most of the cases the liver was examined microscopically, and the only fact
worthy of note observed was the variable amount of fatty matter. Sometimes
it was in excess, sometimes in moderate quantity, or rather deficient, and some-
times, apparently, in greater amount in one portion of the organ than in others."

OaJcum as a Substitute for Lint, in Gun-shot and other Suppurating Wounds.
— Dr. Lewis A. Sayre recommends [Am. Med. Times, Aug. 9, 1862) picked
oakum as a substitute for lint, in all cases of suppurating wounds, particularly
in connection with opened joints, where the suppuration is excessive. The
oakum, he says, is more of an absorbent than lint, and therefore fulfils one of
the objects of dressing better, and another advantage is its cheapness.

" It is necessary," he says, "to place under the wound a piece of India-rubber
cloth, or oiled muslin, for the sake of cleanliness ; and in case of much inflamma-
tion, by simply wetting the oakum in cold water, and wrapping the oiled muslin
around the limb, or wounded part, so as to exclude the air, you have at once the

1862.]

Domestic Summary.

567

neatest and most comfortable poultice that can be applied to it. In gun-shot
wounds, which go through and through a limb, particularly if made with the
' Minie ball,' the whirl or screw of the ball entangles in its thread the muscular
fibres and cellular tissue, and separates them from their attachments for a long
distance from the real track of the ball itself.

"As the muscle and tegumentary tissues are more freely supplied with blood-
vessels than the fat and cellular tissue, the consequence is that they begin to
granulate much more readily than those other tissues, and will thus often close
up the wound, and prevent the free escape of pus, before those parts have per-
fectly healed, and thus lead to the formation of extensive secondary abscesses.
I, therefore, in all cases where no bloodvessels prevent it, pass an eyed probe
through the wound and draw through it a few fibres of the oakum or tarred
rope, which keeps it perfectly free, and the tar is a very excellent antiseptic,
. and removes all unpleasant odour.

" A few fresh fibres are twisted on the end of the seton at every dressing and
drawn into the wound, and the soiled piece cut ofi" and removed with the dress-
ings."

Experiments on the Formation of Infusoria in Boiled Solutions of Organic
Matter, enclosed in Hermetically Sealed Vessels, and supplied with Pure Air. —
Dr. Jeffries Wyman relates [American Journal of Science, July, 1862) some
very ingenious and interesting experiments to elucidate this subject.

Pasteur, in his admirable researches on fermentation, has brought forward
experimental evidence to show that this process depends upon the presence of
minute organisms in the fermenting fluid, and that the source of all such organ-
isms is the atmosphere. In support of this opinion he asserts, that when a fluid
containing organic matter in solution is put into a flask, and "boiled two or
three, minutes," and supplied only with air which has been filtered bypassing
through a tube heated to redness, and the flask is then hermetically sealed, no
• fermentation takes place, no organisms are formed, and that the contents remain
indefinitely without change. But if the same solution is exposed to the air in
its ordinary condition, it becomes filled with various living forms. Out of a
large number of experiments prepared in the manner above described he has not
known one to give a difi'erent result from that mentioned. He further states
that if the neck of the flask is drawn out into a very slender curved tube of
several inches in length, the contents boiled, and then allowed to cool without
the end of the tube being closed, so that the air enters at the ordinary tempera-
ture, and has free access to the interior of the flask, even then no fermentation
takes place and no organisms appear. His explanation of this is, that the air
which enters first, meets with the hot steam, and the spores or organisms con-
tained in it are killed ; while those which enter the tube later move more slowly,
and are deposited on the moist walls of it without entering the body of the
flask.

The results of Dr. "Wyman's experiments have been quite different, and living
organisms have made their appearance, in some instances, where even greater
precautions were taken than those mentioned by Pasteur. "The boiled solu-
tions of organic matter made use of," by Dr. W., "exposed only to air in her-
metically sealed vessels, and exposed to boiling water, became the seat of
infusorial life.

These experiments. Dr. W. observes, " throw but little light on the immediate
source from which the organisms in question have been derived. Those who
reject the doctrine of spontaneous generation in any of the forms in which it
has been brought forward, will ascribe them to spores contained either in the
air enclosed in the flask, or in the materials of the solution. In support of this
view it may be asserted, that it has been proved by the microscopical investiga-
tions of Quatrefages, Robin, Pouchet, Pasteur, and others, that the air contains
various kinds of organic matter, consisting of minute fragments of dead animals
and plants, also the spores of cryptogamous plants, and certain other forms, the
appearance of which, as Quatrefages says, suggests that they are eggs. We
have made some examinations of our own on this subject, but it would be unne-
cessary to give the results in detail. We will simply state, that we have care-

568

American Intelligence.

[Oct. 1862.]

fully examined tlie dust deposited in attics, also that floating in the air collected
on plates of glass covered with glycerine, and have found in such dust, in addi-
tion to the debris of animal and vegetable tissues, which last were by far in the
greatest abundance, the spores of Cryptogams, some closely resembling those of
Confervoid plants, and with them, but much less frequently, what appeared to
be the eggs of some of the invertebrate animals, though we were unable to
identify them with those of any particular species. We have also found grains
of starch in both kinds of dust examined, to the presence of which Pouchet was
the first to call attention. When compared with the whole quantity of dust
examined, or even with the whole quantity of organic matter, both eggs and
spores may be said to be of rare occurrence. We have not in any instance de-
tected dried animalcules which were resuscitated by moisture, and when the
dust has been macerated in water, none have appeared until several days after-
wards, until after a lapse of time, when they would ordinarily appear in any
organic solution.

" Those who advocate the theory of spontaneous generation, on the other hand,
will doubtless find, in the experiments here recorded, evidence in support of
their views. While they admit that spores and minute eggs are disseminated
through the air, they assert that no spores or eggs of any kind have been actu-
ally proved by experiment to resist the prolonged action of boiling water. As
regards Yibrios, Bacteriums, Spirillums, etc., it has not yet been shown that
they have spores; the existence of them is simply inferred from analogy. It is
certain that Yibrios are killed by being immersed in water, the temperature of
which does not exceed 200° F. We have found all motion, except the Brownian,
to cease even at 180° F. We have also proved by several experiments that the
spores of common mould are killed, both by being exposed to steam, and by pass-
ing through the heated tube used in the experiments described in this article.
If. on the one hand, it is urged that all organisms, in so far as the early history
of them is known, are derived from ova, and therefore from analogy, we must
ascribe a similar origin to these minute beings whose early history we do not *
know, it may be urged with equal force, on the other hand, that all ova and
spores, in so far as we know anything about them, are destroyed by prolonged
boiling: therefore, from analogy we are equally bound to infer that Vibrios,
Bacteriums, &c., could not have been derived from ova, since these would all
have been destroyed by the conditions to which they have been subjected. The
argument from analogy is as strong in the one case as in the other."

Singular Case of Hernia. — Prof. Parker related the following singular case
of hernia to the New York Medical and Surgical Society (December 31, 1861).

A young man, enjoying vigorous health, complained for the first time of severe
abdominal pain around the umbilicus and in the right groin, and some sickness
of the stomach, on Monday morning. This not yielding to ordinary remedies,
a physician was called, who regarded it as a case of colic, and treated it ac-
cordingly. The pain, constipation, and nausea continuing. Dr. Parker was
called In consultation on Thursday. He found the patient with a rapid feeble
pulse, cool surface, a somewhat tumid abdomen, with tenderness in the right
hypogastrium, pain, singultus, and nausea with vomiting. On closer examina-
tion, an oblong tumour, soft and doughy to the feel, and somewhat discoloured,
was found extending from the external abdominal ring upwards and outwards
on the right side three and a half inches towards the anterior superior spinous
process of the ileum. An examination of the scrotum showed that the testicles
had never descended into their vaginal sacs. It was at once decided to cut down
upon the tumour. The incision was made along the long axis of the tumour.
Cutting through the integument and the common fascia, the tendon of the ex-
ternal oblique was divided, and the sac exposed as well as the right testis.
The sac was reversed and extended towards the anterior superior spinous pro-
cess. About ten inches of the ileum had escaped. It was very dark. The
finger was passed in towards the internal ring, which was unusually deep, and
the stricture torn with the finger. The gut brightened immediately, and was
reduced witliout difficulty. I'he patient has probably done well. Dr. P. having
heard nothing since the operation, three weeks ago. — Am. Med. Times, Sept.
13, 18C2.

INDEX.

Abscess, metastatic, 117
Absorbing power of buman skin, 507
Abstinence, prolonged, 278
j^lgopbony as a sign of pleurisy, 240
Ague, treatment of by cincbonise disulpbas,
628 ■

Alcobol, as an aliment in disease, 208

, is it food? 508

Aldis, poisonous effects of coal gas, 274
Amaurosis cured by evacuating aqueous hu-
mours, 257

from carious tootb, 550

from injury to fifth pair of nerves,

, hereditary, 256

American Asylums for the Insane, notices

of reports of, 165, 483
Ammonia, antiseptic properties of, 212
Amputations at Paris hospitals, statistics of,

250

Ansesthetic, local, 253

Anchylosis of hip-joint from rheumatism, 247
Aniline, chorea treated by, 235

, poisoning by, 275

Anstie, alcobol as an aliment in disease, 208
Antimony, iodide and oxyiodide of, 512
Apoplectic and phthisical, probabilities of
life of, 241

Appia, Ambulance Surgeon, notice of, 200
Arm, common injury to, in young children,
563

Arrow wounds, 365
Arterial obstruction, cases of, 518
Ashhurst, abscess of kidney, 116
, burns, 82

, compound comminuted fracture

of skull, &c., 106
, compound comminuted fracture

of thigh, &c., 112

, fracture of sternum, 406

— ■ , mammary carcinoma, 107

, ruptured peritoneum, 114

Atropia paper, 555

Atropia, substitution of daturia for, 212

Auscultation of head, 521

Aveling, displacement of uterus, 189

Baker, monstrosity, 278

, statistics of cancer, 549

Ballard, tactile sensibility of hand, 203
Barclay, medical diagnosis, 202
Barnes, broncho-pneumonia in lying-in wo-
men, 271

, indications for induction of prema-
ture labour, 185

Barthez, pneumonia in infants, 226
Bauchet, resection of elbow, 541
Bayonet, body transfixed by, 283
Begbie, diphtheria and its sequelee, 520
Behier, peritonitis treated by cold to abdo-
men, 270

Belladonna in opium poisoning, 277, 280, 395
Bennett, treatment of pneumonia, 529
Berend, operation for anchylosis of hip-
joint, 247
Bibliographical notices —

American Asylums for the Insane,

165, 483

— > Appia, Ambulance Surgeon, 200

Barclay, Medical Diagnosis, 202

Brown-Sequard on Paralysis, 175

Gairdner, Public Health in Belation

to Air and Water, 192

Gray, Intestinal Obstruction, 180

Headland, Medical Handbook, 506

Milroy on Health of British Navy,

497

Mitchell, Circulation in Snapping

Turtle, 201
Sims, Amputation of Cervix Uteri,

179

Smith, Handbook of Surgical Opera-
tions, 181

Smith, on Haemorrhoids and Prolap-
sus of Rectum, 504

Tourniquet for Armies, 180

Transactions of Obstetrical Society

of London, 182

Transactions of State Medical Socie-
ties, 463

Vedder, Extension and Counter Ex-
tension in Fractures, 179

Walshe on Diseases of Heart and

Great Vessels, 496

Wilson, on Sterility and Spermator-
rhoea, 605

Bickersteth, ligature of common iliac artery,
538

Bill, arrow wounds, 365
Bladder, congenital inversion of, 253
Blake, belladonna in opium poisoning, 280
Blepharo-spasm, 551
Blot, stability of cure of varices, 247
Bones, influence on the growth of, of para-
lysis, &G., 244
Bouchut, ver atria in rheumatic fever, 536
Boudin, marriages of consanguinity, 205
Brassfounders' ague, 238
Braun, retro-uterine hematocele, 273
Breast, abscess of, 187
Briquet, sudden death from emboli, 239
Brodhurst, treatment of old dislocations, 546

510

Index.

Broncho-pneumonia in lying-in women, 271
Brown, ovariotomy, 190
Brown-Sequard, fibrous tumours of uterus,
184

, lectures on paralysis, 175

Bruckner, probabilities of duration of life
in apoplectic and phthisical, 241

Burkhardt, ether and belladonna in stran-
gulated hernia, 253

Burns, treatment of, 82, 242

Butler Hospital for Insane, notice of report
of, 165

California Insane Asylum Report, notice of,
173

Camp measles, fungi of wheat straw as a

cause of, 17
Camphorated chloroform as a local anassthe-

tic, 253
Cancer, statistics of, 549
Cancrum oris, treatment of, 227
Carcinoma of mamma, 107
Cardiac murmurs, 29
Carditis in a child, 187
Carotid, ligature of common, 245
Castella, fracture of rib by a sneeze, 249
Cataract, frequent eTacuation of aqueous

humour for, 255
China, medical missionary's hospital in, 99
Chlorate of potash in phthisis, 223
Chloride of barium, tetanus cured by, 243
Chloroform, new preparation of, 215
Cholera infantum, state of liver in, 566
Cholesteremia, 349

Cholesterine, excretion of by liver, 305
Chorea treated by sulphate of aniline, 235

treated by whiskey, 566

Christian, epidemic relationship of zymotic

diseases, 91
Cinchonge disulphas in ague, 528
Clark, acute chorea treated with whiskey,

566

Claude Bernard, calorific and vascular

nerves of the sympathetic, 508
Clover-hay tea in hooping-cough, 278
Coal-gas, poisonous effects of, 274
Cochin China ulcer, 254
Cod-liver and other oils, administration of,

214.

Coffee, influence of on metamorphosis of tis-
sue, 507

CoUis, operations for varicocele and varicose

veins, 246
Collodion, vesicating, 216
Condy, clover-hay tea in hooping-cough, 278
Convulsions, intra-uterine, 272
Cooke, ovarian tumour cured by tapping, 271
Cooper, blepharo-spasm, 551

, epiphora, 554

, intra-ocular effusions, 554

, periorbitis. 553

Cornea, paracentesis of, 552

, staphyloma of, 284

, stone imbedded in, 259

Cotton, iron in consumption, 221

Cowan, spontaneous inversion of uterus, 557

Creasote, solid, 217

Datura, substitution of for atropia, 212

j Davis, hydatid mole expelled from uterus,
I after a living child, 187

I , ligature of common carotid, 245

j Deaf dumbness and marriages of consangui-

! nity, 205

{ Delirium tremens, large doses of digitalis

j in, 224, 532

, therapeutics of, 531

Demarquay, dislocation of foot forwards, 248
Diabetes mellitus. saccharine treatment of,

! 232

j with spinal irritation, 520

I Diarrhoea, subnitrate of bismuth in, 231
i Dickson, smallpox, 54

I , treatment of acute rheumatism. 534

I Digitalis in delirium tremens, 224

, large doses of, in delirium tre-

I mens, 224, 532

Diphtheria and its sequelae. 520
! Dislocation of ulna forwards, 248
' of foot forwards,' 248

Dislocations, treatment of old, 546

Dobell, review of, on germs and vestiges of

disease, 157
Donovan, hyoscyamus, 218
Druit, liquid essence of beef, 186
Duclos, treatment of acute dysentery, 534
Duncan, internal surface of uterus after de-
livery, 265

, opium poisoning treated by bella-
donna, 277
Duriau, strychnia poisoning, 562
Dysentery, treatment of, 231

, subnitrate of bismuth in, 231

. treatment of acute, 534

Ear, polypus of, 285

Earle, pelvimeter. 187

Elbow, resection of, 541

Ellis, rennet wine, 510

Emboli, sudden death from, 239

Embolism of arteria centralis retinae, 258

Epidemic typhoid fever from use of impure

water, 518
Epilepsy, remedies for, 235
. review of Revnolds on, 134

I Epiphora, slitting up canaliculus for, 554

Evolution, case of, 185

Exhaustion, substitute for brandy in, 185

Eye-instruments, gilt and non-metallic, 556
j Eye, loss of from bite of leech, 259

, review of Williams on Diseases of, 441

Femur and pelvis, wounds of, 109

• , compound comminuted fracture of.

I &c., 112

, continuous extension in fractures of,

Fever, quinine as a prophylactic, 122
Fifth pair of nerves, amaurosis &g., from

injury of, 70
Flecken, twins, one dead at six months, both

retained until full term, 266
Flint, excretory function of liver, 305

on cardiac murmurs, 29

Food in typhoid fever, 218
Foetus, diagnosis of sex of, 266
Foot, dislocation of, 248
Fourgeaud, puerperal ureemia, 103

Ind

EX.

Fox, vessels concerned in production of

phlegmasia dolens. 558
Fracture of patella, 249
of rib, 249

Fractures of femur, India rubber for conti-
nuous extension in, 88
Fremy, therapeutic properties of malt, 212
Fungi of wheat straw as a cause of measles,
17, 387

Gairdner, public health in relation to air

and water, 192
Gangrene, oxygen baths for, 548
Gardner, therapeutic properties of podo-

phyllin, 210
Gaubert, subnitrate of bismuth in diarrhoea

and dysentery, 231
Gay, intestinal obstruction by solitary band,

179

Giraud-Teulon, strabismus rectified by pris-
matic glasses, 259
Glycerole of tar, 515
Gnecchi, tetanus cured, 243
Goodfellow, arterial obstruction, 518
Graefe, loss of eye from bite of leech, 258
Greenhow, brass founders' ague, 238
Guepin, hemorrhage in anterior chamber of

eye, 261
Gunshot wound of lung, 250

Haemorrhoids and Prolapsus of Rectum, no-
tice of Smith on, 504

Halahan, mechanism of labour, 261

Hand, tactile sensibility of, 203

Harley, pathology and treatment of jaun-
dice, 230

Hatherly, pelvic cellulitis, 188

Hawks, double monster, 191

Haydon, syphilitic disease after vaccination,
232

Hays, syrup of triticum repens in irritable

bladder, 279
Head, auscultation of, 521

, elongation of foetal, 187

Headland's Medical Handbook, notice of,

506

Heart, liability to affections of in rheuma-
tism under different remedies, 535
■ , notice of Walshe's Treatise on Dis-
eases of, 496
Hemorrhage in anterior chamber of eye,

supplementary to menstrual flow, 261
He-rard, food in typhoid fever, 218
Hernia, incarcerated. 111

, singular case of, 568

Hewitx, elongation of foetal head, 187

, polypus of uterus, 190

Heyfelder, lesection of astragalus, 541

Hicks, uterine polypi, 190

Hodges, a common injury to arm in very

young children, 563
Holmes, polypus of ear, 285
Holthouse, fracture of patella, 249
Hooping-cough, clover-hay tea in, 279

, nitric acid in, 284

Hughes, saccharine treatment of diabetes

mellitus, 232
Huguier, umbilical hernia, 352

Humphrey, influence of paralysis, &g. on

growth of bones, 244
Hutchinson, stone imbedded in cornea for

seven months, 259
Hydatid mole expelled from uterus after a

living child, 187
Hyoscyamus, extract and tincture of the

leaves of, 218

Iliac aneurism, 537

artery, ligature of common, 538

Infusoria, formation of, 567
Inman, is alcohol food, 508
Insane and idiotic in the U. S., statistics of,
483

Insane, notice of Reports of American In-
stitutions for, 165, 483

Intra-oeular effusions, 554

Iowa Hospital for Insane, notice of report of,
490

Iron in consumption, 221
Irwin, body transfixed by bayonet, recovery,
283

Jaundice, pathology and treatment of, 230
Jobert, substitution of daturia for atropia,
212

Johnston, pseudencephalic monster, 96
Jordan, inversion in strangulated hernia,
548

Joset, properties of wild thyme, 511
K.

Keiller, cancrum oris, 227

, induction of premature labour, 263

Kentucky, notice of Report of Western Lu-
natic Asylum of, 489
Kerr, stone in the bladder, 99
Kidney, abscess of, 116
Kunkler, diabetes with spinal irritation, 520

Labour, mechanism of, 261
Lambert, elastic tourniquet, 180
Landouzy, agophony as a sign of pleurisy,
240

Laugier, oxygen baths in local gangrene,
648

Lawson, paracentesis of cornea, 552
Lee, compound fracture of sacrum, 113

of skull, 114

, deformity of legs, 110

, incarcerated hernia. 111

, rupture of urethra, 108

Leet, gangrene of lung, 107

Lefort, method of detecting minute traces of

morphia, 276
Legs, deformity of, 110

Lente, amaurosis and other disorders of eye
from injury of fifth pair of nerves, 70

Lewin, connection between poisoning by
phosphorus and fatty liver, 275

Lieberich, embolism arteria centralis retinse,
258

Life and organization, review of theories of,
119

Ligature of common carotid, 245
Little, influence of abnormal parturition, <&c.
on condition of child, 189

5Y2

Index.

Liver, in cholera infantum, 566 1

, new excretory function of, 305

Long View Lunatic Asylum, notice of report

of, 488 j
Lowe, congenital inversion of bladder, 253 j
Lung, gangrene of, 107
, gunshot wound of, 250

McCiintock, turning in cases of dispropor-
tion, 556

Mackenzie, chorea treated by sulphate of

aniline, 235
Madge, smallpox in twin foetuses, 187

, uterine hemorrhage, 184

Malt, therapeutic properties of, 212

Manche, taenia solium, 240

Manifold large doses of digitalis in delirium

tremens, 532
Marriages of consanguinity, 205
Martenot, extirpation of toe nail, 253
Massachusetts Lunatic Asylum, at Taunton,

notice of report of, 494
State Lunatic Asylum, at

Northampton, notice of report of, 495
Mayo, idiopathic carditis in a child, 187
> , presentation of right shoulder and

arm, 185
Meadows, hernia of ovary, 191

, pericarditis in a child, 186

Measles, fungi of wheat straw as a cause of,

17, 387
Milk abscess, 187

Mitchell, circulation in snapping turtle, 201

, marriages of consanguinity, 205

Monster, double, 191

, pseudencephalic, 96

Morphia, mode of detecting minute traces !

of, 276 I
Monstrosity, 278 |
Mussey, Health, its Friends and Foes, review

of, 461

Napper, defective formation of skin round

umbilicus, 183
Navy, health of royal, 495
New Hampshire Asylum for Insane, notice

of report of, 493
New Jersey, notice of Transactions of State

Medical Society of, 476
State Hospital for Insane, notice

of report of, 170
Newman, eighteen pregnancies and only

seven living children, 191
New York, notice of Transactions of State

Medical Society of, 463
Nitrate of silver in acute dysentery, 534
Nitric acid in hooping-cough, 284
Nitro-benzol, poisoning by, 275
Noble, nitric acid in hooping-cough, 284
Noeggerath, inversion of uterus reduced, 283
Norris, opium poisoning treated by bella-
donna, 395

Noyes, staphyloma cornea, iridectomy, 284
Nunn, milk abscess, 187

Oakum as a substitute for lint, 566
Obstetrical Society of London, notice of
Transactions of, 182

Ohio, Northern Lunatic Asylum Report, no-
tice of, 172, 488

, Hamilton County Lunatic Asylum Re-
port, notice of, 173, 488

Ophthalmoscope, 554

Opium poisoning, belladonna, 277, 280, 395

Ord, prolonged abstinence, 278

Oswald, cinchonise disulphas in ague, 528

Ovarian tumour cured by tapping, 271

Ovariotomy, 183, 190

Ovary, hernia of, 191

Ozanam, preparation of oxygenated water,
511

Packard, deficiency of ribs, 118
, Indian rubber for making continu-
ous extension in fractures of femur, 88

, metastatic abscess, 117

-, singular lesion of urinary bladder,

105, ib.

, wound of femur and pelvis, 109

Paracentesis of cornea, 552

Paralysis, notice of Brown-Sequard, Lec-
tures on, 175

Parker, singular case of hernia, 568

Patella, fracture of, 249

Pathological Society of Philadelphia, pro-
ceedings of, 105

Patton, pumpkin seeds in taenia, 284

Pelvimeter, Earle's, 187

Pelvic cellulitis, 188

Pelvis, fracture of, &c., 115

Pennsylvania, notice of Transactions of
State Medical Society, 479

Pericarditis in a child, 186

Periorbitis, 553

Peritoneum, ruptured, 114

Peritonitis treated by cold to abdomen,
279

Peroxide of hydrogen, therapeutic proper-
ties, of, 209
Phlegmasia dolens, vessels concerned in pro-
duction of, 558
Phosphorus, poisoning with, 275
Phthisis, quinia in, 533

■, chlorate of potash in, 223

Pleurisy, Eegophony as a sign of, 240
-, treatment of, 226

Pneumonia in infants, 226

•, treatment of, 529

Podophyllin, medicinal properties of, 210
Poggiale, inhalation of pulverized fluids,
214

Poisoning by aniline, 275

— by nitro-benzol, 275

by phosphorus, connection with

fatty liver, 275

by strychnia, 562

by upas tieute, 561

bv vegetable alkaloids, 413

Polli on sulphites, 513

Pollock, difficult position of head of twins,

185

Polvpus of ear destroyed by persulphate of
iron, 285

Pregnancy and labour unsuspected, 265
Premature labour, induction of, 185, 263
Public health in relation to air. water, &c.,
192

Puerperal phlegmonous erysipelas, 269

Index,

5t3

Pulmonary consumption, conditions aflFecting
the constitution of persons, 236

• , iron in, 221

Pulverized fluids, inhalation of, 214

Quinia as a prophylactic of fever, 221
R.

Railway travelling, influence of on public
health, 559

Ranking, therapeutics of delirium tremens,
531

Rennet wine, 510
Resection of astragalus, 541

of elbow, 541

Retro-uterine hematocele, 273

Retzius, puerperal phlegmonous erysipelas,

269
Reviews —

, Dobell, Germs and Vestiges of

Disease, 157

, Mussey, Health : its Friends and

Foes, 448

— , Radcliflf on Epilepsy, 134

— , Reynolds on Epilepsy, 134

, Saurel and Rochard, Naval Sur-
gery, 149

' , Smith, Health and Disease, 448

, Theories of Life and Organization,

119

, Williams on Diseases of the Eye,

441

Rheumatic fever, veratria in, 536
Rheumatism, treatment of acute, 535
Rhode Island, notice of Transactions of State

Medical Society of, 473
Rib, fracture of by a sneeze, 249
Ribs, deficiency of, 118

Richardson, therapeutic properties of per-
oxide of hydrogen, 209

— ^— , antiseptic properties of ammo-
nia, 212

Ricord, transmission of syphilis by vaccina-
tion, 525
Rochard, Cochin China ulcer, 254
Roger, auscultation of head, 521
Roser, treatment of burns, 242

Sacrum, compound fracture of, 113
Salisbury, fungi of wheat straw as a cause

of measles, 17, 387
, poisoning by vegetable alkaloids,

413

Salt, influence on metamorphosis of tissue,
607

Salter, amaurosis from abscess of antrum,
550

Sayre, oakum as a substitute for lint, 566
Sedgwick, hereditary amaurosis, 256
Sex of foetus, diagnosis of, 266
Sidey, intra-uterine convulsions, 272
Sims, amputation of cervix uteri, 179

, vaginismus, 190

Skin, absorbing power of, 507
Skinner, new preparation of chloroform, 215
Skull, compound comminuted fractures of,
543

, fracture of, 106, 114

Smallpox, and the means of prevention, 54

Smallpox in twin foetuses, 187
Smart, quinine as a prophylactic of fever,
221

Smith, Handbook of Surgical Operations,
181

, Health and Disease, review of, 448

, influence of temperature on yellow

fever, 531

, liver in cholera infantum, 566

, statistical inquiry relative to phthisis,

236

: Sneeze, fracture of rib by, 249
Sperino, frequent evacuation of aqueous

humour for absorption of cataract, 255
Spermatorrhoea and Sterility, notice of Wil-
son on, 505
Stanislaus Martin, solid creasote, 217
Staphyloma corneae, iridectomy, 284
Steinback, diagnosis of sex of foetus, 266
Sternum, fracture of, 406
Stone in the bladder, cases of, 99
Strabismus, cure of divergent by prismatic

glasses, 259
Strangulated hernia, 253
Strangulated hernia, inversion in, 548
Streatfield, atropia paper, 555
, gilt and non-metallic eye instru-
ments, 556
Sulphites, a new series of salts, 513
Suspended animation, report on, 516
Sympathetic, calorific and vascular nerves
of, 508 •

Syphilitic disease after vaccination, 239
in phthisis, 633

Syphilis, transmission of by vaccination, 525
Syme, iliac aneurism, 537

Tactile sensibility of hand, 203
Tsenia solium, 240
Taenia, seeds of pumpkin for, 284
Tanner, fibrous tumour of uterus, 182

, unsuspected pregnancy and labour,

265

Tar plasma, 515

Taylor, non-shortening of supra and infra-
vaginal portions of cervix uteri, 281
Tetanus cured by chloride of barium, 243
Thompson, absorbing power of skin, 507
Thymus serpillum, medical properties of, 511
Tiehborne, vesicating collodion, 216
Toe nail, extirpation of, 253
Trelat, statistics of amputations, 250
Triticum repens, syrup of in irritable blad-
der, 279
Trousseau, pleurisy, 226
Turning in cases of disproportion, 556
Twins, one dead at six months, both retained

until full term, 266
Tyler Smith, ovariotomy, 183
Typhoid fever, food in, 218
from use of impure water, 518

Ulna, dislocation of forwards without frac-
ture of olecranon, 248
Umbilical hernia, diflficulties in treatment of,

252

Umbilicus, defective formation of skin round,
182

5Y4

Index.

United States Government Hospital for In-
sane, notice of report of, 484

, statistics of insane and idiotic

in, 483

Upas tieute, poisoning with, 561
Uraemia, puerperal, 103
Urethra, rupture of, 108
Urinary bladder, lesions of, 105
Urine, effects of retention after parturition,
190

Uterine hemorrhage, 184

, polypi, 190

Uterus, displacement of, 189

, fibrous tumour of, 182, 184

■ , internal surface of after delivery,

265

, inversion of reduced, 283

, polypus of, 190, 191

, spontaneous inversion of, 557

Vaccination, transmission of syphilis by, 535
Vaginismus, 190
Valves of veins, 204

Van den Corput, iodide and oxyiodide of an-
timony, 512

Varices, stability of cure of, 247

Varicocele and varicose veins, operations for,
246

Vedder, extension and counter-extension in

fractures, 179
Veins, valves of, 204
Veratria in rheumatic fever, 536

Verneuil, valves of veins of extremities, 204
Virginia, Western Asylum, notice of report
of, 171

Voit, influence of salt and coffee on meta-
morphoses of tissue, 507

Walshe on diseases of heart and great ves-
sels, notice of, 496

Wallace, administration of cod-liver and
other oils, 214

Wells, effects of retention of urine after par-
turition, 190

Whiskey, acute chorea treated with, 566

Wild thyme, medical properties of, 511

Williams, compound comminuted fractures
of skull, 543

, on Diseases of the Eye, review of,

441

Wisconsin State Hospital for the Insane Re-
port, notice of, 174

Wisconsin State Hospital for Insane, notice
of report of, 492

Woods, gunshot wound of lung, 250

Wyman, formation of infusoria, 567

Yellow fever, influence of temperature on,
521

Zinc, disease produced by fumes of, 238
Zymotic diseases, epidemic relationship of, 91

American Journal of Med. Sciences.

5t5

UNIYERSITY OF PENNSYLYANIA.

At a Public Commencement, held March 13, 1862, in the Musical Fund Hall, the
degree of Doctor op Medicine was conferred bj Rev. Daniel R. Goodwin, D. D.,
Provost, upon the following gentlemen ; after which an Address was delivered
by Joseph Leidy, M. D., Professor of Anatomy.

NAME.

Aiken, John
Bailey, W. D.

Barber, John
Bartine, D. H.

TOWN OR P. 0.

Chester Valley,
Dillsburg,

Mercer,
Philadelphia,

COUNTY.

Chester,
York,

Mercer,

Batdorff, Daniel T.
Beveridge, Thomas T.
Black, John J.

Mt. Etna,
Andover,
New Castle,

Berks,
Victoria,
New Castle,

Blackwood, Wm. R. D. Philadelphia,

Boardman, C. H.
BoUes, Lucius S.
Boyer, S. P.
Brendle, George F.

Brown, J. Morris

Philadelphia,
Providence,
Reading,
Rehrersburg,

Providence,

Berks,

Cincinnati, Hamilton, Ohio.

Jr.

Bruch, W. J. H.
Buchanan, Jas. A.,
Buchanan, Wm. F.
Campbell, Wm. H.
Carll, George G.
Cleemann, Richard A. Philadelphia
Clement, James M

Phillipsburg, Warren,
Philadelphia,
Philadelphia,
Philadelphia,
Salem, Salem,

Comly, Ezra, Jr.

Dexter, Geo. B.
Dick, George H.
Dickey, Robert

Dieffenderfer, E. L.
Dodd, Edward
Drane, Henry A.
Drown, Thomas M.
Du Bois, Frank L.
Eckstein, H. C.

Flynn, John
Frink, Edward A.

Gibson, J. R.
Good, James M.

Lombard ville, Cecil,
Byberry, Philadelphia,

Philadelphia,

West Chester, Chester,

Bloomsburg,
New York,
Philadelphia,
Philadelphia,
New London,
Philadelphia,

Columbia,

Chester,

Philadelphia,
South Deer Isle, Hancock,

Philadelphia,

West Chester, Chester,

STATE. SUBJECT OF THESIS.

Pa. Dysentery.
Pa. Typhoid or Enteric Fe-
ver.

Pa. Medicine Clinique.

Pa. Development of Mind
and Body.

Pa. Enteric Fever.

N. B. Acute Bronchitis.

Del. Diabetes, with a Review
of Dr. Povey's New
Theory in regard to
the Saccharine Func-
tions of the Liver.

Pa. Gastro-intestinal Diges-
tion.

Pa. De Novo Ansesthetico.
R. L Infant Alimentation.
Pa. Scope of Surgery.
Pa. Fracture of the Crani-
um, producing com-
pression of the Brain.
Respiration, with its Ef-
fect upon Nutrition.
N. J. Prostatorrhoea.
Pa. Erysipelas.
Pa. Oleum Terebinthinae.
Pa. Variola.
N. J. Gunshot Wounds.
Pa. Heat Depression.
Md. Predisposition to Den-
tal Caries.
Pa. Administration of Medi-
cine.

Phthisis Pulmonalis.
Pa. Enteric or Typhoid Fe-
ver.

Pa. Bronchocele.
N. Y. Fractures.
Pa. Morbus Coxarius.
Pa. Urological Chemistry.
Pa. Delirium Tremens.
Pa. Contagion and Infec-
tion.

Pa. The Encephalon.

Me. Typhoid or Enteric Fe-
ver.

Pa. Fatty Degeneration.
Pa. Iritis.

Nova Scotia.
Pa.

American Journal of Med. Sciences.

NAME.

TOWN OR p. 0.

COUNTY. STATE.

SUBJECT OF THESIS.

Grross, Henry S.

Philadelphia,

X d.

Variola.

(jrutn, iiawara r.

Philadelphia,

Pa.

Gonorrhoea.

Hallman, N. F.

Slatington,

Lehigh,

Pa.

Diphtheria.

Handy, D. Claude

Annapolis,

Ann Arundel,

Md.

Modus Operandi of Me-
dicines.

Hickman, Napoleon

Lewes,

Sussex,

Del.

Ansemia.

Eixon, Llojd W.

Lowell,

Middlesex,

Mass.

Rachitis.

Holbrook, Silas P.

North Wren-
tham,

Norfolk,

Mass.

The Alimentary Canal
and its Functions.

Jack, J. A.

Pottstown,

Montgomery,

Pa.

Delirium Tremens.

Jolinson, Wm. H.

Philadelphia,

Pa.

Circulation of the
Blood.

Kauffman, J. H.

Miners ville,

Schuylkill,

Pa.

Diseases and Injuries

peculiar to Coal Mines.

Kendall, Lucian H.

Reading,

Berks,

Pa.

Medical Observations

among the Japanese.

King, Robert D.

Amherst, Cumberland, N. Scotia.

Puerperal Uterine He-

Kratz, Harvey Plumsteadville,

Bucks,

Pa.

DiplitliGriSr.

Laros, John A.

Coopersburg,

Lehigh,

Pa.

Light, Abia H.

U. S. A.

Enteric Fever.

Long, Manoah S.

Long Swamp, Berks,

Pa.

Physical Diagnosis.

Maas, Abraham

Philadelphia,

Pa.

Caloric as a Remedy

Magoffin, Montrose M.

Mercer,

Pa.

Infantile Hygiene.

McBride, J. A.

Philadelphia,

Pa.

Labor.

McClure, Allan A.

Nassau, New Providence, "W. Ind. Yellow Fever.

McMurtrie, Daniel

Danville,

Pa.

Professional Relations.

Merillat, Wm. C.

Staunton,

Augusta,

Va.

Blindness.

Middleton, P.

Darby,

Delaware,

Pa.

Digestion.

Miles, Samuel N.

Maugerville,

Sunbury,

N. B.

Diphtheria.

Miller, S. J. Fergus

Washington,

Fayette,

Ohio.

Death.

Nebingerj George W.

Philadelphia,

Pa.

Scarlatina — Its Treat-
ment.

Noyes, Hiram J.

Haverhill,

Essex,

Mass.

The Circulation of the

Blood.

Nonamaker, J. H.

Fisherville,

Dauphin,

Pa.

Curatio Contrarionem

per Contraria.

O'Farrell, Gerald D.

Philadelphia,

Pa.

Typhus Fever.

Orendorff, Charles

Delavan,

Tazewell,

111.

Indigenous Remedies
for Endemic Diseases.

Peltz, Samuel H. Schuylkill Falls, Philadelphia,

Pa.

Intermittent Fever.

Plunkett, Philip M.

Wilmington,

Del.

Gunshot Wounds.

Purdy, Silas

Amherst,

Cumberland,

N. S.

Rubeola.

Raub, Jno. A.

Blairstown,

Warren,

N. J.

Opium.

Rice, John M.

Philadelphia,

Pa.

Delirium Tremens.

Richardson, J. G.

Philadelphia,

Pa.

Primary Treatment of
Burns.

Richardson, M. C. B.

New Berne,

Craven,

N. C.

Gunshot Wounds.

Roberts, Jacob

U. S. A.

Typhoid Fever.

Robinson, Charles M.

Fairfield,

Adams,

Pa.

Diphtheria.

Rogers, Richard R.

Trenton,

Mercer,

N. J.

Duties of a Physician in

the Lying-in Cham-
ber.

American Journal of Med. Sciences.

NAME.

Ruch, S. W.
Saville, John J.

Sawyer, Robert Gr.
Saylor, Joliu H.
Shirk, Adam
Smith, T. W. T.
Stovell, Matthew
Styer, Charles
Taylor, Joseph
Thomas, Richard, Jr.
Todd, James Reeve
Townshend, A. S.
Turner, A. Paul
Wedel, H. R.

Welsh, Thomas, Jr.
Wood, Horatio C, Jr.
Young, I. Gilbert
Young, J. Watson

TOWN OR P. O. COUNTY. STATE.

Allentown, Lehigh, Pa.
Denver City, Colorado Ter.

Harbor Island, West Indies.

Columbus, Franklin, Ohio.
Jonestown, Lebanon, Pa.
Warwickshire England.

Philadelphia,
Norristown,
Kennett Sq.
Trenton,
Barbadoes,
Amherst,
New Harmony, Posey,
Winona, Winona,

Pa.

Montgomery, Pa.
Chester, Pa.
Mercer, N. J.

West Indies.
Nova Scotia.
Ind,
Minn.

Davidsonville, Ann Arundel, Md.
Philadelphia, Pa.
Kensington, Philadelphia, Pa.
Lambertville, Hunterdon, N. J.

SUBJECT OF THESIS.

Peritonitis.

Diseases of the Rocky
Mountain Region.

Epidemic Cholera.
Dysentery.
Unhealthy Ulcers.
Erysipelas.
Collodion.
Enteric Fever.
Circulation of the Blood.
Arsenical Poisoning.
Typhus Fever.
Haemoptysis.
Hemorrhoids.
Lead and its Prepara-
tions.

Vis Medicatrix Naturse.
Enteric Fever.
Croup.
Pneumonia.
Total . . 92

IJNIYERSITY OF PENNSYLVANIA— PHILADELPHIA.

MEDICAL DEPARTMENT.
NINETY-SEVENTH SESSION, 1862 AND 1863.

William Gibson, M. D.,
George B. Wood, M. D.,
Samuel Jackson, M. D.,

Hugh L. Hodge, M. D.,

Joseph Carson, M. D.,
Robert E. Rogers, M. D.
Joseph Leidy, M. D.,
Henry H. Smith, M. D.,
William Pepper, M. D.,
William Hunt, M. D.,

Emeritus Professor of Surgery.

Emeritus Professor of Theory and Practice of Medicine.

Professor of Institutes of Medicine.
f Professor of Obstetrics and the Diseases of Women and
t Children.

Professor of Materia Medica and Pharmacy.
, Professor of Chemistry.

Professor of Anatomy.

Professor of Surgery.

Professor of Theory and Practice of Medicine.
Demonstrator of Anatomy.

The Lectures of the Session will begin on the second Monday of October and close
on the first of March.

One Introductory will be delivered to the Course.

Clinical Instruction is given throughout the Session, in the Medical Hall, by the
Professors, and at the Pennsylvania and other Hospitals.

-The Dissecting Rooms, under the superintendence of the Professor of Anatomy and
the Demonstrator, are open from the middle of September.

The room for Operative Surgery and the Apphcation of Bandages, &c., is open
early in September and throughout the Session, under the supervision of the Pro-
fessor of Surgery.

Surgical Demonstrators, . . . | & f ^''T' m'

^ ' \ H. Lenox Hodge, M. D.

Fees for the Lectures (each Professor ^15) $105

Matriculation Fee (paid once only) 5

Graduation Fee .......... 30

R. E. ROGERS, M. D., Dean of the Medical Faculty.

University Building.

SAMUEL PRICE, Janitor, University Building.
P. S, — Board may be had at from $2 50 to $6 per week.
No. LXXXYIIL— Oct. 1862. 31

518

American Journal of Med. Sciences.

JEFFERSON MEDICAL COLLEGE— SESSION 1862-63.

Robert M. Huston, M, D.,

Emeritus Professor of Materia Medica and General
Therapeutics.

Ti 1X1- T\T -TV r Emeritus Professor of Obstetrics and Diseases of
Charles D. Meigs, M. D., | ^^^^^ Children.

Institutes of Medicine, ....

General, Descriptive and Surgical Anatomy,
Chemistry, ......

Institutes and Practice of Surgery,
Materia Medica and General Therapeutics,
Practice of Medicine, ....

By Prof. RoBLET Dungltson, M. D.
" Joseph Pancoast, M. D.
" Franklin Bache, M. D.
" Samuel D. Gross, M. D.
" Thomas D. Mitchell, M.D.
" S. Henry Dickson, M.D.

Obstetrics and Diseases of Women and Children, " Ellerslie Wallace, M.D.

Clinics will be held regularly in September; and every Wednesday and Saturday
in October, and during the course, Medical and Surgical cases will be investigated,
prescribed for, and lectured on before the Class. During the year ending March the
first, 1862, a large number of medical and surgical cases were treated, and numerous
surgical operations performed ; among them many of the most important.

The lectures are so arranged as to permit the student- to attend the clinics of
the Pennsylvania Hospital, and the Philadelphia Hospital.

On and after the 1st of October, the dissecting-rooms will be open, under the direc-
tion of the Professor of Anatomy and the Demonstrator.

FEES.

Matriculation, which is paid only once, $ 5

To each Member of the Faculty $15, 105

Graduation, ........... 30

ROBLEY DUNGLISON, M.D.,

Dean of the Faculty.

BOYLSTON MEDICAL PRIZE QUESTIONS.

The Boylston Medical Committee, appointed by the President and Fellows of Har-
vard University, consists of the following Physicians: —

Edward Reynolds, M. D. J. B. S. Jackson, M. D. Charles G. Putnam, M. D.
John Jeffries, M. D. J. Mason Warren, M. D. Morrill Wtman, M. D.
S. D. TowNSEND, M. D. D. H. Storer, M. D. Henry J. Bigelow, M. D.

At the Annual Meeting of the Committee on Wednesday, August 6th, a premium of
Sixty Dollars, or a gold medal of that value, was awarded to Francis Minot, M. D.,
of Boston, for the best dissertation on the question —

On Nausea and Vomiting, as Symptoms ; under what circumstances do they occur, and
what indications do they afford as to the seat and character of disease?

The following are proposed for 1863 : —

1. On Trephining the Skull for Injury or Disease.

2. On Leucocylhssmia.

Dissertations on these subjects must be transmitted, post paid, to Edward Rey-
nolds, M. D., on or before the first Wednesday of April, 1863.

The author of the best dissertation considered worthy of a prize on either of the
subjects proposed for 1863, will be entitled to a premium of ninety dollars, or a gold
medal of that value.

The following questions are proposed for 1864: —

1. On the Treatment of Fractures without Splints.

2. The Remittent Fever now prevailing in the United States Army.

Dissertations on these subjects must be transmitted as above, on or before the first
Wednesday in April, 1864,

The author of the best dissertation considered worthy of a prize for 1864, will be
entitled to a premium of ninety dollars, or a gold medal of that value.

Each dissertation must be accompanied by a sealed packet, on which shall be written

American Journal of Med. Sciences.

519

BOYLSTON MEDICAL PRIZE QUESTIONS— Continued.
some device or sentence, and within which shall be inclosed the author's name and
residence. The same device or sentence is to be written on the dissertation to which
the packet is attached.

The writer of each dissertation is expected to transmit his communication to Ed-
ward Reynolds, M. D., President of the Board, in a legible handwriting, within the
time specified.

All unsuccessful dissertations are deposited with the Secretary, from whom they
may be obtained, with the sealed packet unopened, if called for within one year after
they have been received.

By an order adopted in 1826, the Secretary was directed to publish annually the
following votes : —

1st. That the Board do not consider themselves as approving the doctrines con-
tained in any of the dissertations to which premiums may be adjudged.

2d. That in case of publication of a successful dissertation, the author be considered
as hound to print the above vote in connection therewith.

J. MASON WARREN,

Secretary.

Publishers of newspapers throughout the country are respectfully requested to
notice the above.

HARVARD UNIYERSITY.

SUMMER SESSION OF THE MEDICAL DEPARTMENT.

The Annual Course of Summer Instruction in the Medical Department of Harvard
University will commence at the Massachusetts Medical College, in North Grove
Street, Boston, on Monday, March 10, 1862, and continue till November.

Clinical, Medical and Surgical Instruction will be given at the Massachusetts Gene-
ral Hospital, adjoining the College.

Recitations from approved text-books will be held daily during the session at the
College, upon all branches necessary to a medical education. Occasional lectures are
also given, and demonstrations, illustrated by the Museums of the College.

During the Summer Session, instruction is given by lectures at Cambridge, on
Botany, by Prof. Gray; on Comparative Anatomy, by Prof. Wyman; on Zoology, by
Prof. Agassiz ; on Acoustics and Optics, by Prof. Lovering. To these lectures, stu-
dents of the Summer Session will be admitted without extra charge.

Good Board can be obtained at .1>3 00 or $4 00 per week.

Fees for the Summer Term (which must be paid in advance), $100, without extra
charge for Matriculation, Hospital, Library or Dissections; for six months, $100; for
three months, $50.

D. Humphreys Storer, M. D., Professor of Obstetrics and Medical Jurisprudence.
John B. S. Jackson, M. D., Professor of Moi^bid Anatomy.
Henry I. Bowditch, M. D., Professor of Clinical Medicine.
Oliver W. Holmes, M. D., Professor of Anatomy and Physiology,
George C. Shattuck, M. D., Hersey Professor of the Theory and Practice of Medi-
cine.

Henry J. Bigelow, M. D., Professor of Surgery and Clinical Surgery.
John Bacon, M. D., Professor of Chemistry.

Edward H. Clarke, M. D,, Professor of Materia Medica.

David W. Cheever, M. D., Demonstrator.

Wm. E. Coale, M. D., Assistant in Theory and Practice.

Francis Minot, M. D., Assistant in Theory and Practice.

Richard M. Hodges, M. D., Assistant in Surgery.

Calvin Ellis, M. D., Assistant in Morbid Anatomy.

J. Nelson Borland, M. D., Assistant in Clinical Medicine.

James C. White, M. D., Assistant in Chemistry.

Fitch E. Oliver, M. D., Assistant in Materia Medica.

Tickets to the Session must be procured before students will be admitted to the
Course.

D. HUMPHREYS STORER, Dean of the Faculty,

No. 132 Tremont Street, Boston.
Circulars can be obtained gratis, upon application to David Clapp,^ Medical and
Surgical Journal Ofl&ce, over 334 Washington Street, Boston.

Oct. 1862.]

BLA.NCHARD & LEA'S NEW MEDICAL PUBLICATIONS.

• NEW AND GREATLY IMPROVED EDITION— (Now Ready.)

A SYSTEM OF SURGERY;

DIAGNOSTIC, PATHOLOGICAL, THERAPEUTIC, AND OPERATIVE.
BY SAMUEL D. GROSS, M, J).,

Professor of Surgery in tke Jefferson Medical College of Philadelphia, &c.

SECOND EDITION,

MUCH ENLARGED AND CAREFULLY REVISED.

With Twelve Hundred and Twenty -seven Illustrations ;

A LARGE NUMBER OF WHICH ARE FROM ORIGINAL DRAWINGS.

In two very large octavo volumes, of about 2200 closely printed pages; strongly bound in leather,

with raised bands, $12.

The exhaustion in little more than two years of a large edition of so elaborate and comprehen-
sive a work as this is the best evidence that ihe author was not mistaken in his estimate of the
want which exisied of a complete American System of Surgery, presenting the science in all its
necessary details and in all its branches. That he has s-ucceeded in the attempt to supply this want
is shown not only by the rapid sale of the work, but also by the very favorable ma.iner in which
it has been received by the organs of the profession in this country and in Eurrpe, and by the fact
that a translation is now preparing in Holland — a mark of appreciation not often bestowed on any
scientific work so extended in size.

The author has not been insensible to the kindness thus bestowed upon his labors, and in revising
the work for a new edition he has spared no pains to render it worthy of the favor with which it
has been received Every portion has been subjected to clo>e examination and revision ; any de-
ficiencies apparent have been supplied, and the results of recent progress in the science and art of
surgery have been everywhere introduced ; while the series of illustrations has been enlarged by
the addition of about three hundred wood cuts, rendering it one of the most thoroughly illustrated
works ever laid before the profession. To accommodate these very extensive additions the work
has been printed upon a smaller type, so that notwithstanding the very large increase in the matter
and value of the book, its size is somewhat more convenient and less cumbrous than before, while
the price has not been increased. Every care has been taken in the printing to render the typo-
graphical execution unexceptionable, and it is confidently presented as a work in every way worthy
of a place in even the most limited library of the practitioner or student.

The gecoiid edition hears evidence of careful revision,
on nearly every page; and whole sections of new matter
prove with what; care and paiustabiug the distinguished
author has labored to render his work worthy of the
patronage of the profession. We cannot enter into even
a specification of the additions which have been made,
but will simply add that the work is still the most com-
plete exponent of the science and art of surgery in our
language.— J.}n-. 3Ied. Times, May 8, 1862.

"We cannot but regard these two volumes as consti-
tuting the most comprehensive system of surgery that
we have extant, excelling that of Chelius in many most
important respects. — British Am. Journal, April, 1862.

It is too well known to require extended notice here.
Its plan is most comprehensive, and its character is
truly encyclopasdic. Manuals and treatises in this de-
partment of medical science are by no means rarities;
the medical press teems with them ; it is therefore espe-
cially gratifying that Dr. Gross' work holds its own
among iis numerous competitors, and we know of no
other which so fully answers the purpose for which it
■was written — that of '"furnishing a systematic and com-
prehensive treatise on the science and practice of sur-
gery considered in the broadest sense." — Boston Med.
and Surg. Journal, May 8, 1862.

Thus it will be seen that in this second edition Prof.
Gross has not spared any trouble to bring his labors to
a level with contemporary science; and his System is
so far encyclopaedic, that the student of surgery will
rarely ref\^r to it without finding some valuable informa-
tion on the subject of his search. — The London Lancet,
April 26, 1862.

The fact of this important work having, in the space
of less than three years, reached a second edition, is a
proof that it must have almost superseded, at least on
the American continent, all other general treatises on
the subject. That in so doing it is but justly appreci-
ated, a mere glance over its contents, and the style in
■which it is got up, has fully satisfied us— in fact, the

System of Surgery of Prof. Gross may he said to be ex-
haustive, at least in so far as the term can be applied
to a work on a science which is so rapidly progressing.
It is a work that should find a place in every medical
man's library, however extensive, and one that cannot
well be dispensed with, from the oflBce shelves of the
general practitioner. — Pacific Med. and Surg. Journal,
March, 1862.

Gross' System of Surgery is a work of which the most
eminent surgeon that ever lived might justly be proud
to have been the author. — Am. Med. Monthly, July, 1862.

It is but little more than a year since we had to wel-
come the first edition of this voluminous work ; and in
the present edition the author has given us no cause for
withdrawing any part of the favor with which we re-
ceived the earlier issue. We find that a considerable
amount of new matter has been introduced, and a
smaller type used. We are glad to learn that a trans-
lation of this work into the Dutch language is now in
progress at Nieuwediep, in Holland; and we trust it
may be as well appreciated in that country as it has
been in our own. — Brit, and Foreign Med.-Chir. Review,
July, 1862.

The work has been received throughout the land as
the masterpiece of a leading surgeon, and as a crowning
effort of one whose name has for a long time stood the
most prominent in our surgical literature. The appre-
ciation of the work abroad has been a universal com-
mendation, and its translation into one European lan-
guage has already advanced. It is, beyond comparison,
the most comprehensive work on surgery in any lan-
guage, and as an exponent of the claims of American
surgery, so much ignored in the foreign reprints, our
national pride should interest us in its pntronage. With
our appreciation of the work as the greatest individual
achievement with which American medical literature
has yet been honored, and being aware how extensively
it is known and valued, we have thought it unnecessary
to do much more than announce the appearance of a
second edition. — Med. and Surg. Eeporter, March 15, 1862.

Date Due

JouYlr^Qltk

ned/ca/ Sc/ehcej

Wew 5e\-ies

1 e> t £

SMfTHSONIAN INSTITUTION LIBRARIES

3 9088 01224 9645

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